Low Titer Antinuclear Antibodies Research Articles

Serum amyloid P deposition is a sensitive and specific feature of membranous-like glomerulopathy with masked IgG kappa deposits

Membranous-like glomerulopathy with masked IgG kappa deposits (MGMID) is a recently described pattern of glomerulonephritis with a unique histopathology. The pattern is characterized by subepithelial and/or mesangial immune deposits that are “masked”, to immunoglobulin staining by routine immunofluorescence but strongly stain for IgG and kappa light chain after protease digestion. Patients with this pattern of glomerulonephritis are most commonly young females presenting with proteinuria and a vague history of autoimmune disease such as low titer antinuclear antibodies. Here we compared the mass spectrometry profile of laser capture microdissected glomeruli from nine MGMID renal biopsies with eight biopsies showing other patterns of membranous glomerulopathy. The protein most significantly increased in MGMID was serum amyloid P. Immunostaining showed serum amyloid P colocalized with IgG in the glomeruli of MGMID but not with PLA2R-associated membranous glomerulopathy. Serum amyloid P was positive in the glomeruli of all 32 MGMID biopsies but negative in biopsies of other types of membranous glomerulopathies such as those associated with PLA2R and THSD7A. There were four biopsies with glomerular serum amyloid P staining among the 173 biopsies that did not fulfill criteria for MGMID or amyloidosis. All four of these biopsies with positive serum amyloid P staining had a membranous pattern of glomerulopathy with IgG kappa deposits that only differed from MGMID by the lack of “masking”. Thus, positive staining within glomerular deposits for serum amyloid P identifies a unique form of glomerulonephritis likely sharing a common pathophysiologic mechanism of disease.

Adult onset Still's disease: experience from a tertiary care rheumatology unit

Adult-onset Still's disease (AOSD) is a rare chronic inflammatory disorder presenting with prolonged fever and polyarthritis. Retrospective study of patients with AOSD, seen between 1992 and 2009 at a large tertiary care hospital. Twenty-nine patients (18 female) with median age at onset of 28 (17-58) years were seen. The clinical features included fever in 29, inflammatory polyarthritis in 26, sore throat in eight and typical rash in 13. Lymphadenopathy was present in 15, hepatomegaly in 15, splenomegaly in 13 and serositis in five patients. Anemia was present in 22, neutrophilic leukocytosis in 28 and thrombocytosis in 13 patients. Acute phase reactants were elevated in all. Fifteen patients had transaminitis. Low titer antinuclear antibodies were present in 6/28 patients. On median follow-up (25 patients) of 23.7 months (range: 3-84) one patient had self-limited or monocyclic pattern, eight had polycyclic and 16 had chronic articular pattern. All patients received non-steroidal anti-inflammatory drugs and 25 received methotrexate and/or prednisolone. During the course 14 patients had remission and of these six were in remission on drugs at last follow-up. One patient received tociliziumab and was in clinical remission. One patient developed macrophage activation syndrome and one had atlanto-axial dislocation. Three patients developed tuberculosis and two died of infection associated with immunosuppression. AOSD is an uncommon disorder with 1-2 patients seen at a large tertiary care rheumatology unit. Overall AOSD has a fair outcome with significant morbidity and most needing long-term therapy with steroids and methotrexate.

Occult hepatitis C: How convincing are the current data?

Occult hepatitis C: How convincing are the current data?

Immuotactoid Glomerulopathy (Fibrillary Glomerulonephritis)

Immunotactoid glomerulopathy first was described in 1977, when Rosenmann and Eliakim (1) reported an unusual glomerular lesion in a 45-yr-old woman who presented with the nephrotic syndrome and renal insufficiency. The electron microscopy was remarkable for organized electron-dense deposits in the form of randomly arranged fibrils that measured 10 nM in diameter. The deposits were associated with mesangial expansion and immune deposits of IgG, IgM, and C3 in a mesangial pattern. Congo red stain of the deposits was negative, and there was no clinical or serologic evidence of a systemic disease. They interpreted the deposits to be “amyloid-like” and speculated that they might represent a “preamyloid” state. In 1980, Schwartz and Lewis (2) reported a case of a 49-yr-old man who presented with the nephrotic syndrome and no evidence of systemic disease and had a similar renal lesion: Immune aggregates were associated with highly organized electron-dense deposits that were composed of microtubules that were arranged in parallel bundles. During 7 yr of follow-up, the patient progressed to renal failure but never demonstrated any clinical or serologic evidence of a systemic disease. To distinguish this lesion from other disorders that have glomerular immune deposits associated with highly organized microtubular or fibrillary structures, such as amyloidosis, cryoglobulinemia, paraproteinemias, and systemic lupus erythematosus (SLE), the term immunotactoid glomerulopathy (ITG) was coined, reflecting the composition (immuno-) and polymeric morphology (tactoid) of the glomerular deposits. In the past 25 yr, >200 cases of ITG have been reported (3–5). Various synonyms have been used to refer to the lesion that is described in these reports, including fibrillary glomerulonephritis (FGN), nonamyloidotic fibrillary glomerulopathy, amyloid-like glomerulopathy, and amyloid stain–negative microfibrillary glomerulopathy, but we believe that they all represent the same or a similar disease process (6–8). The unifying feature in all of the cases …

Utility of age, gender, ANA titer and pattern as predictors of anti-ENA and -dsDNA antibodies

Monovariate and multivariate analyses including logistic regression were performed to determine associations among predicting variables [age, gender, immunofluorescence pattern, and anti-nuclear antibody (ANA) titer] and anti-extractable nuclear antigen (ENA) and -dsDNA antibodies (Abs) in 1089 patients with positive fluorescent ANA (FANA) test results. Samples with high titer ANAs had an increased frequency of anti-ENA and -dsDNA Abs. The receiver operating (ROC) curves of the ANA titer for anti-ENA Abs had a larger under the curve area compared to the ROC curve for anti-dsDNA Abs, indicating that ANA titer is better for predicting anti-ENA Abs than anti-dsDNA Abs. There was no relation noticed between immunofluorescence patterns and anti-ENA and -dsDNA Abs except an increased frequency of anti-dsDNA Abs found in samples with a homogeneous pattern. Probability calculations on the basis of the ANA pattern and the titer showed that samples with low titer ANAs (1:160 or less) had low probabilities for anti-ENA Abs (0.002-0.009) regardless of immunofluorescence patterns. However, samples with a homogeneous pattern at any titers including low titers had high probabilities for anti-dsDNA Abs. A decreased frequency of anti-dsDNA Abs as measured by Crithidia assay was noticed in samples from patients aged 50 or older. In contrast, no association was noticed between age and anti-ENA Abs. There was no female preponderance found in the presence of anti-ENA and -dsDNA Abs. In conclusion, our study shows that the ANA titer but not the immunofluorescence pattern is useful in predicting anti-ENA Abs. In contrast, both the ANA titer and the immunofluorescence pattern help in predicting anti-dsDNA Abs. Samples with low titer ANAs (1:160 or less) may not need a further test for anti-ENA Abs unless an ANA-associated disease is highly suspected. However, a test for anti-dsDNA Abs should be considered in samples with a homogeneous pattern at any titer including low titers.

Update in Sjögren syndrome.

Sjögren syndrome (SS), the second most common autoimmune rheumatic disease, refers to keratoconjunctivitis sicca and xerostomia resulting from immune lymphocytes that infiltrate the lacrimal and salivary glands. However, differential diagnosis remains confusing due to the high prevalence of vague symptoms of dryness, fatigue, and myalgias in the general population. The problems of diagnosis are further compounded by the finding of "positive" antinuclear antibodies in a high percent of the general population. Unless minor salivary gland biopsies are read by experienced observers, nonspecific changes of sialadenitis are frequently confused with the focal lymphocytic infiltrates that are characteristic of SS. The distinction between fibromyalgia patients with low titer antinuclear antibodies and primary SS remains difficult. Even in patients fulfilling strict criteria for SS, the genomic search for critical genes has proven difficult due to the multigenic pattern of inheritance and strong role of currently undefined environmental factors. No single environmental factor has been detected in the majority of SS patients. SS-like syndrome has been detected in certain patients with HTLV-1 and hepatitis C infection, providing clues to pathogenesis. Even in SS patients with marked sicca symptoms, minor salivary gland biopsy shows that almost 50% of glandular cells are still detected on biopsy. These results imply the importance of immune factors such as cytokines and autoantibodies in decreasing neuro-secretory circuits and induction of glandular dysfunction. Of potential importance, an antibody against muscarinic M3 receptor that can decrease secretory function when injected into rodents is frequently found in the sera of SS patients. Newly developed topical and oral therapies can ease the oral and ocular dryness. Orally administered agonists of the muscarinic M3 receptor (pilocarpine and cevimeline) have recently been approved by the US Food and Drug Administration to increase salivary secretion. Topical ocular use of low-dose corticosteroids or cyclosporin may decrease conjunctival surface inflammation. In a Phase II double-blind study, orally administered interferon alpha (150 U) led to improved saliva flow and symptoms. In pregnant patients with evidence of fetal distress, oral dexamethasone is preferred because this agent crosses the placenta effectively. In animal models, antagonists of tumor necrosis factor and inhibitors of de novo pyrimidine synthesis appear promising.

Low-titre auto-antibodies predict autoimmune disease during interferon-alpha treatment of chronic hepatitis C.

In this study, we determined whether low-titre auto-antibodies are a risk factor for the development of autoimmune disease during interferon-alpha (IFNalpha) therapy for chronic hepatitis C (CHC) infection. Eighty-three patients with circulating hepatitis C virus RNA and chronic viral hepatitis on liver biopsy, who had not received IFNalpha, were assessed for serum auto-antibodies (anti-nuclear antibodies (ANA), anti-smooth muscle antibodies, thyroid microsomal antibodies, thyroglobulin antibodies) and thyroid function tests. Thirty-five patients had one or more pre-existing auto-antibody. The majority were low titre ANA. Seven of the 35 patients had clinical autoimmune disease or immune-mediated disorders, predominantly thyroid disease. Twenty patients with low titre auto-antibodies received treatment with IFNalpha and of these 20 patients, six patients developed adverse effects with a possible auto-immune basis. In comparison, only five of the 48 patients without auto-antibodies had immune-mediated disorders and no patient developed autoimmune complications during therapy with IFNalpha. These results suggest that the presence of low-titre auto-antibodies may be a risk factor for the development of autoimmune dysfunction during IFNalpha therapy for chronic hepatitis C. Patients with no detectable auto-antibodies have a low risk for developing autoimmune complications during treatment with IFNalpha.

Evolving concepts of diagnosis, pathogenesis, and therapy of Sjögren's syndrome.

Differences in diagnostic criteria for Sjögren's Syndrome (SS) have led to confusion in the research literature and in clinical practice. A particular challenge is the clinical diagnosis of the patients with sicca symptoms, fibromyalgia, chronic fatigue, vague cognitive defects, and a low titer antinuclear antibody. Until recently, many of these patients would have been classified as primary SS using the European criteria. A suggested revision of the European criteria will require inclusion of anti SS-A antibody or characteristic minor salivary gland biopsy, leading to greater agreement between European and San Diego criteria. Recent studies have emphasized that lacrimal and salivary gland flow involves an entire "functional" unit that includes the mucosal surface (the site of inflammation), efferent nerve signals sent to the midbrain (lacrimatory and salvatory nucleus), efferent neural signals from the brain, and acinal/ductal structures in the gland. Thus, symptoms of dryness or pain can result from interferences with any part of this functional unit. The initiating antigens in SS remain unknown, but immune reactivity against SS-A, SS-B, fodrin, alpha- amylase, and carbonic anhydrase have been demonstrated in patients with established disease. The inflammatory process in the gland releases metalloproteinases that alter the relationship of epithelial cells to their matrix, an interaction that is necessary for glandular function and survival. Therapies for SS remain inadequate. In SS patients with immune-mediated extraglandular manifestation (ie, lung, kidney, skin, nerve), the therapeutic approach is similar to systemic lupus erythematosus, although these therapies have relatively little effect on tear or saliva flow.

Vasculitis confined to peripheral nerves.

The clinical, electrophysiological and pathological features and prognosis of 25 patients with vasculitis selectively affecting the peripheral nervous system were evaluated. Although most patients had a history of mononeuritis multiplex or an asymmetrical neuropathy six out of 25 had a symmetrical neuropathy, both clinically and on neurophysiological testing, by the time of presentation. There were no signs of accompanying systemic vasculitis in any of the patients and serological abnormalities were limited to an elevated erythrocyte sedimentation rate (ESR) in nine out of 21 patients and low titre anti-nuclear antibodies in four out of 20 patients. Most patients had a necrotizing vasculitis on nerve biopsy, although in some cases the diagnosis was made on the association of inflammatory cell infiltrates with extensive axonal degeneration and immune complex deposition on immunofluorescence studies. The mean time from symptom onset to diagnosis was 46 weeks. All patients were treated with corticosteroids and most with additional immunosuppressive therapy. In contrast to vasculitic neuropathy associated with systemic vasculitis the prognosis was good with 24 out of 25 survivors at a mean of 176 weeks follow-up having a mean improvement of 1.4 units on a six-point disability scale.

Antinuclear Antibodies in Pleural Fluid

Systemic lupus erythematosus (SLE) frequently involves the pleura with resultant pleural effusion. Previous studies have reported that detection of antinuclear antibodies (ANA) in pleural fluid using animal tissue as substrate was a sensitive and specific method for distinguishing SLE pleural effusions from other etiologies. The HEp-2 ANA, which uses a human cell line as substrate, is now the preferred ANA test; however, to our knowledge, no studies on pleural fluid using this assay have been reported. To determine its sensitivity and specificity, when measured in pleural fluid, HEp-2 ANA levels were determined in pleural effusion samples associated with a variety of different etiologies, including SLE, malignancy, congestive heart failure, pneumonia, tuberculosis, and a miscellaneous group of diseases. Pleural fluid ANA results were positive in 14 of 82 samples. Six of the eight (75 percent) pleural fluid samples collected from patients with SLE were ANA positive, and all but one had high titers (> 1:160) with a homogenous staining pattern. The remaining two patients with SLE with negative pleural fluid ANA had recurrent pulmonary emboli and congestive heart failure, rather than lupus pleuritis. Eight of 74 patients (10.8 percent) without clinical evidence of SLE had a positive pleural fluid ANA, with the majority having a speckled pattern. High titers were noted in three. These results indicate that a negative or low titer ANA and a speckled staining pattern in pleural fluid from a patient suspected of lupus pleuritis suggest an alternative diagnosis. High pleural fluid titers (up to 1:640) were seen occasionally in patients with inflammatory pleural effusions in the absence of SLE.

L-Tryptophan Ingestion Associated with Eosinophilic Fasciitis but Not Progressive Systemic Sclerosis

To assess the use of L-tryptophan by patients with eosinophilic fasciitis and compare this with its use by patients with progressive systemic sclerosis (scleroderma). Retrospective and prospective analysis. Six patients with eosinophilic fasciitis were identified retrospectively and two prospectively. Retrospective identification of patients was done by questioning hospital-affiliated rheumatologists and dermatologists and by searching the hospital dermatopathology database. The patients with scleroderma or morphea were prospectively identified by questioning consecutive office patients with these established diagnoses. University of Pennsylvania rheumatology and dermatology practices. Eight patients with eosinophilic fasciitis; 40 consecutive patients with scleroderma (27 with diffuse cutaneous and 13, limited cutaneous disease); 3 patients with morphea. All eight patients with eosinophilic fasciitis had taken L-tryptophan before the onset of their disease. All had myalgias and high peripheral eosinophil counts (most greater than 5000 cells/mm3). Only 1 of 40 patients with scleroderma (no patients with morphea) had used L-tryptophan preceding illness (P less than 0.001 compared with eosinophilic fasciitis). Six patients with eosinophilic fasciitis had taken L-tryptophan for less than 8 months. One patient had taken it for 9 years before developing skin induration. Two patients were newly identified as having hypothyroidism; two developed neuropathy; and two had severe flexion contractures (several occurring in areas without skin induration). Five patients had low-titer antinuclear antibodies, indicating a possible autoimmune process. Most patients had only a partial response to systemic corticosteroid therapy. One patient has had important disease regression in response to isotretenoin therapy that was evident even while she continued to take L-tryptophan. L-Tryptophan use can lead to eosinophilic fasciitis whereas it does not appear to cause classic scleroderma. The disease process does not automatically remit after discontinuation of L-tryptophan-containing products.

Autoantibody Formation in Burn Patients after Inhibition of Suppressor T Cell Activity with Polymyxin B

After thermal injury, treatment with polymyxin B blocks suppressor T cell activity by uncoupling endotoxin-mediated T cell activation, but the effect on autoantibody formation is unknown. We examined the presence of antinuclear antibodies to native DNA; to soluble antigens Ro/SSA, La/SSB, Sm, nRNP; and to antiepithelial antibodies in 12 burn patients before and after treatment with polymyxin B and in 24 samples from control burn patients. Low titer antinuclear antibody activity was detected in 25% of pretreatment and 78% of posttreatment samples (p less than 0.01) and in 16.7% of control patients. One polymyxin B-treated patient had a significant antinuclear antibody titer both before and after treatment. Antiepithelial antibodies were detected in 16.7% of early polymyxin B-treated samples and 11.1% of late samples (p less than 0.05) but were also present in 20.8% of controls. Antibodies to native DNA, Ro/SSA, La/SSB, Sm, and nRNP were not detected in any sera.

Sicca syndrome and anti-SSA/Ro antibodies in patients with suspected or definite multiple sclerosis.

Thirty-eight consecutive patients with primary Sjögren's syndrome (SS) and 36 with suspected (15 cases) or probable to definite (21 cases) multiple sclerosis (MS) underwent thorough neuropsychiatric and rheumatological examinations in order to detect either the presence of central neurologic involvement in SS or the presence of clinical and immunologic abnormalities typical of SS in MS. The only neuropsychiatric abnormality we found in patients first recorded for primary SS was major depression in 5 cases. On the other hand, one patient with suspected MS because of mild gait ataxia and right hemiparesis fulfilled the diagnostic criteria for SS. As for serologic tests, 6 out of 21 patients with probable to definite MS and 1 out of 15 with suspected MS had low-titre antinuclear antibodies. One patient with definite MS had also circulating anti-SSA/Ro antibodies, detected by gel double diffusion, but did not develop sicca symptoms after a 2-year follow-up. In the present study, the association between SS and MS was considerably weaker than that recently reported in other studies, and might be regarded as a chance finding.

Lymphocytic hypophysitis in a man.

Fewer than 20 patients with lymphocytic adenohypophysitis have been reported, all of them women, and it usually occurs during pregnancy or the postpartum period. We report the recognition of lymphocytic adenohypophysitis in a man. The patient presented with anterior hypopituitarism and an intrasellar mass on computed tomography. Antipituitary antibodies, found in only one of the previous patients, were not present in this man, although low titer antinuclear antibodies were found. The implications of this latter finding are unclear. The patient's histocompatibility antigen (HLA) types were A2, B8, Bw58, DR1, and DR5. The degree of pituitary failure seemed out of proportion to the size of the mass seen on computed tomographic scan.