Criteria For Connective Tissue Disease Research Articles

Identification and Prognosis of Patients With Interstitial Pneumonia With Autoimmune Features.

Patients classified as interstitial pneumonia with autoimmune features (IPAF) have interstitial lung disease (ILD) and features of autoimmunity but do not fulfill criteria for connective tissue diseases (CTDs). Our goal was to identify patients classifiable as IPAF, CTD-ILD, and idiopathic pulmonary fibrosis (IPF) from a preexisting pulmonary cohort and evaluate the prognosis of patients with IPAF. We reviewed the medical records of 456 patients from a single-center pulmonary ILD cohort whose diagnoses were previously established by a multidisciplinary panel that did not include rheumatologists. We reclassified patients as IPAF, CTD-ILD, or IPF. We compared transplant-free survival using Kaplan-Meier methods and identified prognostic factors using Cox models. We identified 60 patients with IPAF, 113 with CTD-ILD, and 126 with IPF. Transplant-free survival of IPAF was not statistically significantly different from that of CTD-ILD or IPF. Among IPAF patients, male sex (hazard ratio, 4.58 [1.77-11.87]) was independently associated with worse transplant-free survival. During follow-up, only 10% of IPAF patients were diagnosed with CTD-ILD, most commonly antisynthetase syndrome. Despite similar clinical characteristics, most patients with IPAF did not progress to CTD-ILD; those who did often developed antisynthetase syndrome, highlighting the critical importance of comprehensive myositis autoantibody testing in this population. As in other types of ILD, male sex may portend a worse prognosis in IPAF. The routine engagement of rheumatologists in the multidisciplinary evaluation of ILD will help ensure the accurate classification of these patients and help clarify prognostic factors.

Acute myocarditis with autoimmune features: one-year follow-up with CMR

In this prospective study on patients with acute myocarditis (AM), we aimed to describe the new concept of AMAF (AM with autoimmune features) similar to the previously described interstitial pneumonia with autoimmune features (IPAF). IPAF has recently emerged as a new entity, and IPAF patients appear to have fewer episodes of exacerbation and better survival than patients with idiopathic pulmonary fibrosis. Consecutive patients with infarct-like CMR-confirmed AM were classified AMAF if their serologic status measured from blood sampled at presentation was positive (antinuclear antibodies (ANA) ≥ 1:320), but without meeting established classification criteria for connective tissue disease (CTD). The myocardial tissue abnormalities and their progression were assessed on cardiac magnetic resonance (CMR) within 7days following symptom onset and at 1year according to their seropositivity. Among the 64 AM patients included, seven presented AMAF (11%). At baseline CMR, patients with AMAF had half as much late gadolinium enhancement (LGE) as seronegative AM patients (4.41% (1.47-4.41) of myocardial volume versus 8.82% (5.88-14.71), p = 0.01, respectively). At 1-year of follow-up, persistent myocardial scarring was less frequent in AMAF patients (n = 2 (28.6%) than seronegative AM patients (n = 38 (66.7%) (p = 0.021). AMAF, diagnosed as seropositive AM without a specific autoimmune disease, is not rare and is associated with less extensive LGE in the acute phase. In addition, AMAF patients had more favorable outcomes on 12-month CMR. Prospective studies are needed to address the clinical significance of this new concept and its long-term cardiovascular impact.

Myositis-specific Antibodies Identify A Distinct Interstitial Pneumonia with Autoimmune Features Phenotype.

Interstitial pneumonia with autoimmune features (IPAF) characterises individuals with interstitial lung disease (ILD) and features of connective tissue disease (CTD) who fail to satisfy CTD criteria. Inclusion of myositis-specific antibodies (MSAs) in the IPAF criteria has generated controversy, as these patients also meet proposed criteria for an anti-synthetase syndrome. Whether MSAs and myositis associated antibodies (MAA) identify phenotypically distinct IPAF subgroups remains unclear.A multi-center, retrospective investigation was conducted to assess clinical features and outcomes in patients meeting IPAF criteria stratified by the presence of MSAs and MAAs. IPAF subgroups were compared to cohorts of patients with idiopathic inflammatory myopathy-ILD (IIM-ILD), idiopathic pulmonary fibrosis (IPF) and non-IIM CTD-ILDs. The primary endpoint assessed was three-year transplant-free survival. Two hundred sixty-nine patients met IPAF criteria, including 35 (13%) with MSAs and 65 (24.2%) with MAAs. Survival was highest among patients with IPAF-MSA and closely approximated those with IIM-ILD. Survival did not differ between IPAF-MAA and IPAF without MSA/MAA cohorts. Usual interstitial pneumonia (UIP) morphology was associated with differential outcome risk, with IPAF patients with non-UIP morphology approximating survival observed in non-IIM CTD-ILDs. MSAs, but not MAAs identified a unique IPAF phenotype characterised by clinical features and outcomes similar to IIM-ILD. UIP morphology was a strong predictor of outcome in others meeting IPAF criteria. Because IPAF is a research classification without clear treatment approach, these findings suggest MSAs should be removed from the IPAF criteria and such patients should be managed as an IIM-ILD.

Interstitial Pneumonia with Autoimmune Features – An Observational Study in a Tertiary Care Institute from South India

Background: Often, patients with idiopathic interstitial pneumonia (IIP) have certain specific clinical features to suggest an autoimmune disease but do not justify the current rheumatologic classification systems to fit into a diagnosis of connective tissue disease (CTD)-associated IIP. There is a great paucity of clinical, serological, and radiological data of these patients from India. Aim: The aim was to study the clinicoradiological and autoantibody profile in patients with interstitial pneumonia with autoimmune features (IPAF). Methodology: It was a prospective, observational study conducted in a tertiary care center between December 2015 and December 2016. A total of 30 patients who satisfied the criteria for IPAF according to the American Thoracic Society/European Respiratory Society research were included in the study. Results: All 30 patients satisfied IPAF criteria, but they did not meet the immunological criteria for CTD. Majority of them were female (86.67%) and nonsmokers. The mean age was 52.5 ± 14.5 years. The most common clinical symptom was inflammatory arthritis in 20 (66.67%) patients, followed by Raynaud's phenomenon in 5 (16%) patients. Nonspecific interstitial pneumonia was the most common radiological pattern seen in 20 (66.67%) patients, while antinuclear antibody (1:320) was the most common autoantibody positive in 18 (60.0%) patients, followed by rheumatoid arthritis factor in 15 (50%) patients. Conclusions: High female predominance along with distinct imaging, histologic and serological characteristic features are seen in patients with IPAF as compared to those with IIP. Further studies in patients with IPAF are needed to understand the natural history and its management.

Interstitial pneumonia with autoimmune features.

Some patients with idiopathic interstitial pneumonias (IIPs) have clinical features that suggest autoimmune process but not fulfill established criteria for connective tissue disease (CTD). Different terms and criteria have been proposed to describe these patients, which includes undifferentiated connective tissue disease (UCTD), lung dominant connective tissue disease (LD-CTD), and autoimmune-featured interstitial lung disease (AIF-ILD). To marshal these ununiform classification criteria, the "European Respiratory Society/American Thoracic Society Task Force on Undifferentiated Forms of Connective Tissue Disease-associated Interstitial Lung Disease" proposed a consensus regarding the nomenclature and classification criteria for patients with IIP and features of autoimmunity with the term "interstitial pneumonia with autoimmune features" (IPAF). It was reported that patients with IPAF accounted for 7.3%∼34.1% of patients with interstitial lung disease (ILD). Survival, rate of progressing to CTD, appropriate treatment, and treatment response are not yet elucidated. Furthermore, it is not determined whether IPAF is a distinct category of ILD or simply a part of IIP. These questions should be elucidated by future prospective cohort studies. Hopefully, rheumatologists should participate in not only clinical trials but also in multidisciplinary discussions for IPAF.

Lung-Dominant Connective Tissue Disease: Clinical, Radiologic, and Histologic Features

Lung-dominant connective tissue disease (LD-CTD) is a disease concept for interstitial pneumonia; however, it has not been robustly validated. This study was conducted to elucidate the clinical, radiologic, and histologic features of LD-CTD. We retrospectively reviewed 44 consecutive patients with serologically defined LD-CTD who underwent surgical lung biopsy. Patients were identified as having LD-CTD if they had specific autoantibodies but did not meet the criteria for connective tissue disease. We conducted a multidisciplinary diagnosis and evaluated major histologic patterns according to the current idiopathic interstitial pneumonias (IIPs) classification of 2013. Characteristic histologic features for LD-CTD (eg, prominent plasmacytic infiltration, lymphoid aggregates with germinal centers), high-resolution CT (HRCT) scan patterns, and prognosis were also assessed. The major histologic patterns were usual interstitial pneumonia (UIP) in 25 patients and nonspecific interstitial pneumonia (NSIP) in 13 patients. Two or more characteristic histologic features for LD-CTD were observed in 15 patients with histologic UIP (h-UIP) and 11 patients with histologic NSIP (h-NSIP). Fifteen patients with h-UIP (60%) showed an inconsistent UIP pattern on HRCT scan. After multidisciplinary discussion (MDD), 18 patients with h-UIP were labeled as having unclassifiable IIP. The annual change in percent predicted FVC improved significantly in patients with h-NSIP (P = .002), who also had better survival than those with h-UIP (P = .031). In contrast, survival was not associated with HRCT scan pattern (P = .79). The major histologic patterns in LD-CTD were UIP followed by NSIP. Two-thirds of patients had characteristic histologic features for LD-CTD. A majority of patients with h-UIP were considered to have unclassifiable IIP based on MDD. Patients with h-UIP had worse survival than those with h-NSIP.

Lung Involvement in Rheumatic Disease: Introduction

Heterogeneity in the extent and progression of lung fibrosis probably reflects differences in the underlying pathogenic mechanisms. A growing understanding of the key pathogenic drivers of lung fibrosis and of CTDs (including the role of tobacco smoking) might lead to the development of more effective targeted therapies. The key goals of the clinical assessment of patients with both ILD and CTD are the detection of ILD and prognostic evaluation to determine which patients should be treated and how. Recent developments have moved the field forward. Several studies have provided significant advances, especially regarding HRCT-pathologic correlations, prediction of the outcome based on imaging and/or pathology, and the relevance of subtle clinical, serologic and morphologic imaging/pathological findings not fulfilling the criteria for CTDs (a condition now called ‘interstitial pneumonia with autoimmune features’). Demonstration of the efficacy of antifibrotic drugs to slow disease progression in idiopathic pulmonary fibrosis has raised hope that these or other drugs might be effective in fibrotic ILD associated with CTD and foster clinical research. This thematic series sets the scene of CTD principles for a series of papers that will focus on the investigation of lung involvement in rheumatologic disease, the investigation of CTD in ILD, biomarkers, treatment considerations, acute exacerbation and monitoring of lung involvement in rheumatologic disease from authorities in the field. Lung involvement in autoimmune rheumatic diseases is a common manifestation and a major cause of mortality and morbidity. Involvement may include lung parenchyma, airways, pleura, vessels and respiratory muscles. Main differential diagnoses include rheumatic disease manifestation, drug-induced manifestation or infection. Interstitial lung disease (ILD) in connective tissue disease (CTD) can be characterized using the classification of the idiopathic interstitial pneumonias. CTDs as a whole may develop all histologic patterns observed in idiopathic interstitial pneumonias. Systemic sclerosis is most frequently associated with ILD and, in most of these patients, ILD manifests as a histological pattern of nonspecific interstitial pneumonia. Conversely, in rheumatoid arthritis, the pattern of ILD seems to be most often usual interstitial pneumonia. Histologic patterns may be combined, as exemplified by the frequent association of ILD with lymphocytic bronchiolitis in rheumatoid arthritis. Occasionally, lung involvement can present before the diagnosis of CTD, especially in idiopathic inflammatory myopathy and rheumatoid arthritis. In order to decrease mortality, there is a need for early, exact diagnosis and effective treatment. Cooperation of experienced physicians for possible complications, including infections, drug-induced adverse effects, direct or indirect pulmonary or cardiovascular complications, is of paramount importance for the best management. Published online: June 24, 2015

Autoimmune symptoms in idiopathic pulmonary fibrosis: clinical significance.

Information regarding autoimmune symptoms that do not meet the diagnostic criteria for connective tissue disease in patients with idiopathic pulmonary fibrosis (IPF) is limited. The aim of the present study was to investigate differences in the clinical characteristics and prognosis of IPF patients with and without autoimmune symptoms. Consecutive patients diagnosed with IPF (N = 96) from January 2008 to December 2012 were included. We compared the clinical characteristics of patients with and without autoimmune symptoms. Survival was compared by log-rank and Cox proportional hazard analyses. Thirty-six (38%) patients reported autoimmune symptoms. There were no significant differences in clinical characteristics between those with and without autoimmune symptoms. Patients with autoimmune symptoms had a better survival rate than those without symptoms [hazard ratio (HR) 0.27; 95% confidence interval (CI) 0.09-0.82; P = 0.020]. After adjusting for age, gender and smoking status, the presence of autoimmune symptoms was associated with improved survival (HR 0.29, 95% CI 0.09-0.89; P = 0.032). However, after adjusting for other covariates, including per cent predicted forced vital capacity and high-resolution computed tomography total extent score, the presence of autoimmune symptoms did not influence survival (HR 0.49, 95% CI 0.15-1.61; P = 0.240). The median follow-up period for the studied cohort was 31.5 months. It appears that autoimmune symptoms are associated with better prognosis among IPF patients. However, future studies are needed to validate our findings.

Frequency of autoantibodies and connective tissue diseases in Chinese patients with optic neuritis.

BackgroundOptic neuritis (ON) is often associated with other clinical or serological markers of connective tissue diseases (CTDs). To date, the effects of autoantibodies on ON are not clear.PurposeTo assess the prevalence, clinical patterns, and short outcomes of autoantibodies and Sjögren’s syndrome (SS) involvement in Chinese ON patients and evaluate the relationship between ON, including their subtypes, and autoantibodies.MethodsA total of 190 ON patients were divided into recurrent ON (RON), bilateral ON (BON), and isolated monocular ON (ION). Demographic, clinical, and serum autoantibodies data were compared between them with and without SS involvement. Serum was drawn for antinuclear antibody (ANA), extractable nuclear antigen antibodies (SSA/SSB), rheumatoid factor (RF), anticardiolipin antibodies (ACA), and anti-double-stranded DNA antibody (A-ds DNA), anticardiolipin antibody (ACLs), anti-β2-glycoprotein I (β2-GPI) and Aquaporin-4 antibodies (AQP4-Ab). Spectral-domain optical coherence tomography (SD-OCT) was used to evaluate the atrophy of the optic nerve.Results68 patients (35.79%) had abnormal autoantibodies, 26(13.68%) patients met diagnostic criteria for CTDs, including 15(7.89%) patients meeting the criteria for SS. Antibodies including SSA/SSB 23 (30.26%) (p1 and p 2<0.001) and AQP4–Ab10 (13.16%) (p1 = 0.044, p2 = 0.01) were significantly different in patients in the RON group when compared with those in the BON (P1 = RON VS ION) and ION (p2 = RON VS ION) groups. SS was more common in RON patients (p1 = 0.04, p2 = 0.028). There was no significant difference between SSA/SSB positive and negative patients in disease characteristics or severity. Similar results were obtained when SS was diagnosed in SSA/SSB positive patients.ConclusionRON and BON were more likely associated with abnormal autoantibodies; furthermore, AQP4 antibody, SSA/SSB and SS were more common in the RON patients. AQP4 antibodydetermination is crucial in RON patients who will develop NMO. However, when compared with other autoantibodies, SSA/SSB detected in patients was not significantly associated with disease characteristics or severity.

AB1167 Differences and similarities in clinical manifestations and survival between adult-onset and childhood-onset patients with idiopathic inflammatory myopathies

BackgroundIdiopathic Inflammatory Myopathies (IIM) comprise an heterogeneous group of systemic diseases, with an important morbidity and mortality, depending on different age of onset.ObjectivesTo study clinical manifestations, survival and causes of...

FRI0262 Survival and clinical characteristics in patients with idiopathic inflammatory myopathies: Focus on clinical subgroups

BackgroundIdiopathic inflammatory myopathies (IIM) comprise an heterogeneous group of systemic diseases, with an important morbidity and mortality, depending on different clinical subgroups.ObjectivesTo study clinical manifestations, survival, causes of death and...

Diagnosis and Treatment of Connective Tissue Disease-Associated Interstitial Lung Disease

Interstitial lung disease (ILD) is one of the most serious pulmonary complications associated with connective tissue diseases (CTDs), resulting in significant morbidity and mortality. Although the various CTDs associated with ILD often are considered together because of their shared autoimmune nature, there are substantial differences in the clinical presentations and management of ILD in each specific CTD. This heterogeneity and the cross-disciplinary nature of care have complicated the conduct of prospective multicenter treatment trials and hindered our understanding of the development of ILD in patients with CTD. In this update, we present new information regarding the diagnosis and treatment of patients with ILD secondary to systemic sclerosis, rheumatoid arthritis, dermatomyositis and polymyositis, and Sjögren syndrome. We review information on risk factors for the development of ILD in the setting of CTD. Diagnostic criteria for CTD are presented as well as elements of the clinical evaluation that increase suspicion for CTD-ILD. We review the use of medications in the treatment of CTD-ILD. Although a large, randomized study has examined the impact of immunosuppressive therapy for ILD secondary to systemic sclerosis, additional studies are needed to determine optimal treatment strategies for each distinct form of CTD-ILD. Finally, we review new information regarding the subgroup of patients with ILD who meet some, but not all, diagnostic criteria for a CTD. A careful and systematic approach to diagnosis in patients with ILD may reveal an unrecognized CTD or evidence of autoimmunity in those previously believed to have idiopathic ILD.

P137 Practise and Effects of Autoimmune Screening in Pulmonary Fibrosis

Introduction and ObjectivesPatients with pulmonary fibrosis can have features of autoimmune disorders that do not meet criteria for connective tissue disease (CTD), sometimes referred to as autoimmune-featured interstitial lung disease...

Clinical Year in Review II

Clinical Year in Review II

Autoimmune-Featured Interstitial Lung Disease: A Distinct Entity

Patients with interstitial lung disease (ILD) may have features of an autoimmune disorder that do not meet the diagnostic criteria for connective tissue diseases. We determined the prevalence and characteristics of autoimmune-featured ILD (AIF-ILD) and compared these with those of idiopathic pulmonary fibrosis (IPF) and known connective tissue disease-related ILD (CTD-ILD). Patients with ILD who did not meet the criteria for a connective tissue disease were defined as having AIF-ILD if they had a sign or symptom suggestive of a connective tissue disease and a serologic test reflective of an autoimmune process. Clinical characteristics, high-resolution CT images, and lung biopsy specimens were analyzed and compared with those of patients with IPF and CTD-ILD. Survival was evaluated using a Kaplan-Meier curve. Two hundred subjects completed the questionnaire and serologic testing. AIF-ILD was identified in 32%, IPF in 29%, and CTD-ILD in 19%. Gender, age, and race differed among groups (P < .01). Sixty-two percent of patients with AIF-ILD had a typical usual interstitial pneumonia (UIP) pattern on CT images. In 31 patients with AIF-ILD, lung biopsy specimens showed UIP in 81% and nonspecific interstitial pneumonia in 6%. Patients with AIF-ILD and IPF had similar survival, worse than those with CTD-ILD (P < .01). Antinuclear antibody (ANA) titers ≥ 1:1280 were associated with improved survival in patients with AIF-ILD (P = .02). Systematic evaluation of symptoms and serologic tests in ILD can identify AIF-ILD. A UIP pattern on CT images and histopathology is common in AIF-ILD. Although survival for patients with AIF-ILD is poor, ANA titers ≥ 1:1280 are associated with improved survival.

RHEUMATOID ARTHRITIS-SPECIFIC AUTOANTIBODIES ARE PRESENT IN PATIENTS WITH INTERSTITIAL LUNG DISEASE IN THE ABSENCE OF ARTHRITIS.

Purpose To identify rheumatoid arthritis (RA)-related anti-cyclic citrullinated peptide (anti-CCP) in patients with interstitial lung disease (ILD) and no clinical evidence of connective tissue disease, supporting the hypothesis that RA-related autoimmunity may develop in the lung prior to arthritis. Methods This was a cross-sectional descriptive study using a database of subjects with known ILD who had undergone a standardized evaluation. Twelve subjects were identified with an idiopathic ILD and a positive rheumatoid factor in whom anti-CCP testing had been performed. For these subjects, the following data were abstracted: pulmonary diagnosis, gender, smoking status, age at diagnosis of ILD, joint examination findings, and results of anti-CCP antibodies testing. An RF was considered positive if > 20 IU/mL and anti-CCP positive if > 20 units/mL. Results None of the 12 patients had synovitis or other diagnostic criteria for connective tissue disease. Five were positive for anti-CCP antibodies; of these, four had idiopathic pulmonary fibrosis (IPF) and one idiopathic nonspecific interstitial pneumonia (NSIP). Seven cases were anti-CCP negative, with five cases of IPF and two cases of NSIP. Four of the five CCP/RF positive patients were smokers. Although not statistically significant, smoking was associated with increased risk of anti-CCP positivity (OR 3). One patient with RF/CCP positivity developed clinically apparent synovitis 2 years after diagnosis of the lung disease; the other anti-CCP/RF positive subjects did not develop synovitis over 1 to 5 years of follow-up. Conclusions Positive anti-CCP antibody can occur in the setting of an otherwise idiopathic ILD. Given the high specificity of anti-CCP for RA (> 98%), this suggests that the five patients with both RF and anti-CCP positivity are at high risk for the development of RA-specific joint disease. In addition, four of these patients were active smokers at the time of ILD diagnosis. These findings are intriguing and imply, as recent work also suggests, that RA-specific immune dysregulation may initially occur in the lung and may be related to tobacco use. Further studies are needed to establish the longitudinal course of patients with anti-CCP positivity and ILD in the absence of synovitis, as well as the relationship between genetics, environmental exposures, citrullination, and the lung as the site of initiation of RA-specific humoral immunity.

Positive cytoplasmic indirect immunofluorescence on HEp2 cells of unknown pattern: what to report to rheumatologists

The aim of our study was to evaluate antibodies against 'specific liver' antigens in selected sera from patients with positive 'AMA like' and unidentified (UD) Hep2 cytoplasmic immunofluorescence (ctp IIF). Sera of 75 inpatients and outpatients from the Department of Rheumatology, Ljubljana met the inclusion criteria: 36 with AMA-like and 39 with UD pattern. All sera were also negative for anti-M2 and/or antibodies against pyruvat dehydrogenase complex as well as negative to other defined ctp IIF patterns according to European Consensus Finding Study: lysosomal-like, Golgi-like, vimentin-like and actin-like. The majority of patients fulfilled the criteria for connective tissue diseases and rheumatoid arthritis. Antibodies against intracellular antigens were screened by IIF on HEp2 cells (Immunoconcepts, Sacramento, CA, USA). Antibodies against LKM1, SLA, LC1 and Sp100 were performed by line immunoassay (Imtec, Berlin, Germany). There was no difference in AMA-like and UD ctp IIF concerning antibodies against 'specific liver' antigens. A surprisingly high prevalence of positive anti-LKM1 was found in sera regardless of the IIF pattern (Table ​(Table11). Table 1 Antibodies against 'liver specific' antigens in sera with AMA-like and UD ctp IIF Anti-LKM1 has been considered as one of the markers for autoimmune hepatitis type II characterised by fulminant onset and high inflammatory activity according to Imtec data. None of our patients with positive anti-LKM1 had any serious hepatic involvement, therefore they had not been histopathologically evaluated. Only few of them exhibited minor deviations in liver enzymes (less than 1 × upper normal limit). There was slightly lower prevalence of connective tissue disease patients found among UD ctp IIF (Table ​(Table22). Table 2 Antibodies against 'liver specific' antigens in sera with AMA-like and UD ctp IIF An UD ctp IIF pattern is a frequent laboratory finding but it seems not to be of much help to rheumatologists. A search for antibodies against 'specific liver' antigens seems not to be justified for delineation of hepatic involvement in patients with rheumatic diseases. According to the literature in patients with autoimmune hepatitis the meaning of these antibodies is different.

The Prevalence of Antiphospholipid Antibodies in Women With Recurrent Spontaneous Abortion, Women With Successful Pregnancies, and Women Who Have Never Been Pregnant

Antibodies to negatively charged phospholipids are associated with a predisposition to both arterial and venous thrombosis, recurrent fetal wastage, and thrombocytopenia. These associations have been reported in patients who do not fulfill criteria for connective tissue diseases. In this study, we determined the prevalence of antiphospholipid antibodies in 81 women who had had recurrent spontaneous abortion (3 or more fetal losses), in 88 women whose pregnancies were successful, and in 64 women who had never been pregnant. Antiphospholipid antibodies were found in 16% of women with recurrent spontaneous abortion, and at a statistically greater prevalence than in women who had successful pregnancies (7%) as well as those who had never been pregnant (3%). A false-positive VDRL and IgG anticardiolipin antibodies were more specific for fetal wastage than was either the lupus anticoagulant or IgM anticardiolipin antibodies.