Waaler-Rose Test Research Articles

Lung toxicity in a patient treated with sunitinib

To the Editors: A 61-yr-old male presented in 2008 with dyspnoea on exertion and night sweats. Diagnosis of mixed connective tissue disease with pulmonary fibrosis was made. The Latex test, Waaler–Rose test and antinuclear antibodies (anti-centromeres) were positive. The computed tomography (CT) image of the abdomen and pelvis was considered normal at that time. He was started on steroids and the dyspnoea improved. Respiratory functional tests remained abnormal with decreased diffusion capacity of the lung for carbon monoxide (DL,CO) (50%). 6 months later, in April 2009, he developed a fever and macroscopic haematuria. The CT image showed a 9 cm tumour in the left kidney with latero-aortic lymph nodes and multiple lung metastases (fig. 1a). There was also evidence of lung fibrosis. A biopsy of the kidney tumour and a lymph node was performed. The results showed evidence of tubulopapillary renal carcinoma (Furhrman grade II) in the kidney biopsy. The lymph node was involved by a poorly differentiated nonsmall cell carcinoma, different from the kidney lesion. He was referred to the cancer centre. The bone scan and brain magnetic resonance imaging were normal. A left radical nephrectomy with retroperitoneal lymph-node dissection was performed. Pathological examination revealed a 12 cm high-grade (Fuhrman grade IV) mixed renal-cell carcinoma (clear cell carcinoma, tubulopapillary carcinoma and a sarcomatoid component) with lymph node involvement. It was a pT3a pN2 M1 tumour according to the tumour, node, metastasis (TNM) classification. Postoperative bone scan showed multiple metastases. The patient was started on standard sunitinib treatment (50 mg·day−1 for 4 weeks followed by 2 weeks without treatment) in June 2009. Figure 1– Computed tomography …

Inhibition of complement-mediated hemolysis in gel by rheumatoid factors.

When subjected to a hemolysis in gel (HIG) assay for the detection of complement deficiency, 9 of 37 sera from patients with classical rheumatoid arthritis produced impaired lysis of sensitized sheep erythrocytes. All sera were normal in a test for the alternative pathway and no major abnormalities were found within the complement system. Using a two-step HIG technique, with guinea-pig serum as the complement source, all sera were shown to inhibit lysis of sheep erythrocytes sensitized with rabbit IgG. Lysis of IgM-coated erythrocytes was not inhibited. The agglutination titers in a Waaler-Rose test, and the areas of inhibition in the two-step HIG assay with IgG-sensitized erythrocytes, were correlated (r = 0.80, p less than 0.001). Absorption of serum with rabbit IgG coupled to Sepharose 4B, reduced the capacity to inhibit immune hemolysis. The eluate from IgG-Sepharose contained rheumatoid factors and also inhibited immune hemolysis. The findings suggested that rheumatoid factors in serum were responsible for inhibition in the HIG assays used.

Serum concentrations of formation (PINP) and resorption (Ctx) bone turnover markers in rheumatoid arthritis

Joint inflammation in rheumatoid arthritis (RA) induces local periarticular osteoporosis. Generalised bone mineral density (BMD) decrease concerns approximately 50% of rheumatic patients. Both types of bone mass depletion can issue from cytokine-induced (TNF-alpha, IL-1, IL-6) osteoclasts' activation, osteoprotegerin and its ligand's (RANKL) function disorders, patients' immobilisation and glucocorticosteroid (GCS) intake, as well as from hormonal alterations in postmenopausal women, predominate among RA individuals. The aim of the study was to compare serum concentrations of marker of bone formation--serum aminoterminal propeptide of type I collagen (PINP), and bone resorption, carboxy (C) terminal telopeptide (Ctx), bone turnover markers in RA and osteoarthritis (OA) patients and in RA groups of different disease activity, different degree of joint damage and the history of GCS intake. A total of 50 RA female patients and 50 women with knee OA were included in the study. Blood for morphology and biochemistry laboratory tests was taken. Joint X-rays to establish OA and RA diagnosis and the degree of RA progression, as well as DEXA BMD measurements were performed. PINP and Ctx concentrations were assessed. In RA patients the number of swollen and painful joints, the duration of morning stiffness, visual analogue scale values and Waaler-Rose's test activity were recorded. The Disease Activity Index (DAS 28) was counted from the appropriate formula. No differences in bone turnover markers' concentrations were noted neither between RA and OA patients nor between the RA group when compared to the one without the history of GCS use. Bone turnover markers' concentrations in RA were proportional to the number of swollen and painful joints. However, no correlation was found between the markers' concentrations and RA activity assessed by DAS 28 or by laboratory means. Ctx concentrations were higher in patients at II degree joint damage according to Larsen and Dale's than at more advanced stages. Ctx concentrations decreased with the disease duration. Serum morphogenesis and resorption markers' concentrations change in course of RA indicating the decrease in bone metabolic activity with the disease duration and progression. High RA activity and severity correlate with increased markers' levels-the resorption one. The influence of GCS on bone metabolism in RA requires further study.

Does seronegative chronic polyarthritis have a special place? Clinical, biochemical and immunogenetic profile of early seronegative seropositive chronic polyarthritis

In the framework of an early-diagnosis out-patients clinic 100 patients (mean age 51 years), 82 of them female, were identified as highly suspicious of having chronic rheumatoid arthritis of recent onset (2-12 months). Five or more ARA criteria were present in 77 patients. IgM rheumatic factor was present in serum of 51 patients (latex-fixation test). A Waaler-Rose test of greater than or equal to 32 IU/ml was present in 21. After adjusting for alpha errors, there was a significantly higher prevalence of HLA-DR4 among those seropositive in the latex fixation test (64 vs 29%). A further 19 constitutional, anamnestic, clinical, biochemical and psychosocial criteria failed to reveal any different distribution between seropositive and seronegative cases. Using the specific definition of seropositivity in the Waaler-Rose test eliminated HLA-DR4 differences. The latter did not serve as a distinguishing criterion. There was only a marginal difference between DR4-positive and negative patients. These results fail to lend support to recent views of a special position of seronegative chronic rheumatoid arthritis.

291 Orbital Myositis Presenting as Cluster Headache

Background. Cluster headache affects men in the third decade of life. Episodes centers in and around eye, start acutely, last 1 to 2 hours, and occur several times a day. Associated features are ipsilateral conjunctival hyperemia, lacrimation, ptosis, miosis, and facial sweating. Orbital myositis belongs to the group of idiopathic orbital inflammatory syndromes. Clinical picture involves proptosis, conjunctival hyperemia, lid edema, and painful eye movements. Case report. We report on a 13 year-old girl presenting with recurrent and alternating orbital myositis mimicking a cluster headache. At the age of 10 years she first experienced an episode of ocular pain, diplopia, and palpebral edema involving the right eye. Lacrimation, conjunctival hyperemia, nasal rhinorrhea and headache were also observed. The episode lasted 1 month. Neurological examination was normal. Further four episodes affecting the right and the left eyes, alternatively, occurred during a period of 18 months. Cluster headache was initially diagnosed. Neither FANS nor tryptans were able to control clinical symptoms. Magnetic resonance imaging of the orbits showed evident edema and thickening of the correspondent rectus lateralis which subsided after corticosteroids. Idiopathic ocular myositis was therefore diagnosed. The following investigations were performed in several occasions and resulted normal or negative. They included: (i) levels of complement factors and of immunoglobulins; (ii) Raitest and Waaler-Rose test; (iii) research of antinuclear antibody, antibody to ds-DNA, antibodies to extractable nuclear antigens (RNP, Sm, SS/A, SS/B), antisynthetasis (Jo1), antineutrophil cytoplasmic antibody (IFI, antiproteinase 3, antimyeloperoxidase, antilactoferrin). Thyroid function was normal. Viral and bacterial infections were also excluded. Orbital myositis may clinically mimic cluster headache. Conclusions. Orbital myositis should be considered in those patients with atypical cluster headache signs such as painful eye movements and ocular pain which do not resolve after 3–4 hours. An early diagnosis is necessary to plan a proper therapeutic strategy.

Serum cartilage oligomeric matrix protein (COMP) in rheumatoid arthritis and knee osteoarthritis

The cartilage oligometrix matrix protein (COMP) is a noncollagenous protein, a glycoprotein, the function of which is to bind to type II collagen fibres and stabilise the collagen fibre network in the articular cartilage. In the serum of the normal population the COMP level is 5 mug/ml. An increased level of COMP in the synovial fluid was described in the early stage of rheumatoid arthritis (RA), whereas in advanced stages of RA, the level of COMP decreased. In this study we assessed the serum COMP level in patients with RA and knee osteoarthritis (OA) and found a correlation between the serum COMP level and other markers as well as bone mass density (BMD) changes, activity of disease, disease duration and the age of the patients. The blood was collected from 30 RA patients and 30 OA patients who constituted the control group. The serum COMP level was determined using an inhibition enzyme-linked immunosorbent assay (ELISA). The average value of the serum COMP level in RA patients was 10.4+/-3.6 U/l. There was a correlation between the serum COMP level and the age of RA patients (p<0.005) and disease activity score (DAS) value (p<0.01). According to correlation coefficients, the serum COMP level was independent of stage of disease, number of painful and swollen joints, duration of morning stiffness, disease duration and titre of the Waaler-Rose test. The influence of rheumatoid nodule presence on the serum COMP level was shown (p<0.05). In RA patients with erythrocyte sedimentation rate (ESR) values below 20 mm/h compared with patients with ESR values over 60 mm/h, the serum COMP level was observed to be significantly lower (p<0.05). The average value of COMP in OA patients was 10.4+/-2.7 U/l. No correlation was found between the serum COMP level and patients' age and disease duration. There was a correlation between the serum COMP level and Western Ontario and McMaster Universities (WOMAC) index pain scale for the lower limbs (p<0.005) and T-score value of densitometry examinations (p<0.036) in OA patients. No statistical differences were found between the average serum COMP level in RA and OA patients.

Soluble HLA-DR levels in serum are associated with therapy and genetic factors in rheumatoid arthritis

As rheumatoid arthritis (RA) is an HLA-DR associated autoimmune disease and soluble HLA-DR (sHLA-DR) molecules have the capacity to regulate the immune response, we studied the sHLA-DR levels in RA patients in view of therapy modalities and clinical and biologic parameters of disease activity. For this sHLA-DR concentrations from 87 RA patients were determined by a sensitive enzyme-linked immunoabsorbent assay (ELISA) format. There was a weak but significant correlation between sHLA-DR levels and disease activity ( r 0.186 to 0.287, p < 0.004 to < 0.001). The mean serum sHLA were not significantly different between groups with or without corticosteroids, or undergoing therapy with different disease modifying antirheumatic drugs. However, patients treated with a combination of methotrexate and prednisolone have lower sHLA-DR (206 ± 21 ng/ml, n = 34) compared with the mean value for all other samples (306 ± 16, n = 217, p < 0.001). This corresponded with significantly lower EULAR pain and swelling scores, ESR and rheumatoid factor (RF) by latex fixation ( p < 0.02 to 0.001) in the former, compared with the latter group. Furthermore, sHLA-DR was, respectively, 267 ± 15 ng/ml ( n = 182) in samples from patients treated with nonsteroidal anti-inflammatory drugs (NSAIDs), and 358 ± 31 ( n = 72) without NSAIDs ( p < 0.01). Lower sHLA-DR with NSAIDs contrasted with significantly higher scores for pain, swelling, CRP, and RF by latex fixation and by Waaler-Rose test ( p < 0.05 to 0.001). Comparison of subgroups with or without the shared epitope of RA disease (Q)R/KRAA within the HLA-DR β1-chain confirmed significantly higher parameters of disease activity and sHLA-DR in the presence of this disease associated epitope in our patients. Different mechanisms appear to be involved in sHLA-DR production or release, as their level correlates positively with disease activity under combined therapy with corticosteroids and methotrexate, but decreases with higher disease activity in patients treated with NSAIDs.

Antibodies against macaque monoclonal immunoglobulin G in rheumatoid arthritis.

The presence of rheumatoid factors (RF) in the serum of rheumatoid arthritis (RA) patients is commonly evidenced by agglutination tests: the Waaler-Rose assay, based on the use of human red blood cells (RBCs) coated with rabbit anti-RBC antibodies, and the latex test, which uses latex particles coated with denatured human immunoglobulin G (IgG). The aim of the present study was to characterize the RF able to agglutinate human RBCs coated with macaque antihuman RBC IgG antibodies secreted from macaque-mouse heterohybridomas (two from rhesus monkey and one from crab-eating macaque). Human RBCs coated with macaque monoclonal antibodies (MacMoAbs) were used for agglutination tests and these were carried out in parallel with standard tests (Waaler-Rose and latex agglutination tests) on sera from 82 RA patients, 86 patients with other forms of inflammatory chronic arthritis and 47 healthy human subjects. MacMoAb-coated RBCs identified RF in the sera of 66% patients with RA. By contrast, the frequency of positive sera in other inflammatory diseases was 5% and all 47 healthy controls were negative. Antimacaque IgG antibodies were found to be more specific for RF than standard tests, in the sera of patients with RA.

Extravasation of salivary secretions and mumps infection of the submandibular gland

A 37-year-old woman presented with bilateral swelling in the submental region associated with anterior cervical edema extending to the presternal level. The patient first noted swelling on the right side upon waking in the morning 10 days prior to consultation. Swelling progressed rapidly to the left-hand side and cervicothoracic edema developed. The patient did not have fever. Her medical history was significant for Hashimoto’s thyroiditis that had been ongoing since 1985 and responded well to replacement therapy. Physical examination revealed a tender bilateral submental mass without cervical adenopathy. Neither keratoconjunctivitis sicca nor xerostomia were present. Palpation of the front side of the neck and manubrium revealed low-grade cervicothoracic edema involving a gel-like, resistant material. Palpation of the thyroid did not elicit pain. Laboratory findings did not indicate an inflammatory syndrome. Latex and Waaler-Rose tests were negative.

Clinical significance of rheumatoid factors in early rheumatoid arthritis: results of a follow up study.

Serum rheumatoid factors (RF) were measured yearly in 135 women with rheumatoid arthritis by the Waaler-Rose and latex fixation tests and IgM, IgA, and IgG RF were measured by enzyme linked immunosorbent assays (ELISAs). The patients were followed up from an early phase of the disease for a mean duration of six years. Patients with a persistently positive RF test, irrespective of the type of test used, had more radiological abnormalities, more disease activity, worse functional ability, more extra-articular manifestations, and needed more treatment with second line drugs than patients with persistently negative or variably positive and negative test results during the follow up. Increased RF levels, especially a high level of IgA RF within three years of the onset of symptoms, was prognostic for a more severe disease outcome six years after the onset of symptoms.

The Waaler-Rose test: Anatomy of the eponym

The Waaler-Rose test: Anatomy of the eponym

Chicken antibodies: a tool to avoid false positive results by rheumatoid factor in latex fixation tests

19 rheumatoid factor (RF)-positive sera (Waaler-Rose test) and ten control sera were tested in latex agglutination. All RF-positive sera agglutinated latex particles coated with the different mammalian IgGs (cow, horse, human, mouse, sheep and rabbit) and with chicken anti-human C3 (which was used as a positive control), but none of them with non-specific chicken IgG. The control sera were all negative except when tested with chicken anti-human C3. Chicken antibodies should therefore be useful in assays were RF could interfere and give false positive reactions (e.g., nephelometry, latex agglutination or ELISA).

An ELISA for IgA-IgG and IgM-RF measurement. II. RF in several disease and control groups and under gold therapy in RA.

The before introduced solid phase ELISA was employed for the RF determination in the sera of RA patients and controls. The threshold values for positive results (calculated as the 95% distribution percentile of healthy donors) were 8, 3, and 3 U/ml for IgA, IgG, and IgM-RF, respectively. The results confirm the validity of the assay with clear negative results in several negative control groups (healthy donors, patients of the oto-, rhino-, laryngeal ambulance, diabetes mellitus, degenerative arthropathies; n = 111, median IgA, IgG and IgM-RF values of less than or equal to 2, less than or equal to 2 and less than or equal to 1 U/ml, respectively; 25-75% distribution percentiles within the median value) and positive results in the positive control group (seropositive RA; n = 20, median IgA, IgG and IgM-RF values of 324, 479 and 170 U/ml, respectively). 16/24 patients with so-called seronegative RA (negative Latex Fixation Test or Waaler Rose Test) had positive results in the ELISA, two of them had rheumatoid nodules clinically. The IgG-RF activity in the ELISA appears to be a good parameter for the course control of RA under gold therapy. 10 RA patients with clinical improvement of disease (declining ESR, CRP, joint index) after six months of gold therapy (= 0.6 g total gold amount) had a decline of total RF activity of 70% in median, whereas 10 patients with no clear effect on disease activity had only a decline of 20% in median.

Quantitation of Rheumatoid Factors (RF) of IgM, IgA and IgG Isotypes by a Simple and Sensitive ELISA. Discrimination between False and Rue IgG-RF

An enzyme-linked immuno-sorbent assay (ELISA) for quantitation of rheumatoid factors (RF) of IgM, IgA and IgG isotypes has been established. A complex of human serum albumin (HSA) and rabbit IgG anti-HSA antibodies is used as antigen for RF. The binding of RF is detected by stepwise additions of biotinylated monoclonal antibodies specific for human IgM, IgG or IgA, alkaline phosphatase-conjugated streptavidin, and substrate. The assay is simple and applicable to routine testing of large numbers of sera. It discriminates between false and true IgG-RF by papain digestion of sera that turn out positive by the screening for IgG-RF. Of 241 randomly selected patients with rheumatoid arthritis (RA) as well as other rheumatoid and infectious diseases, 110 were Waaler-Rose-positive while 127 were IgM-RF-positive in ELISA. The correlation between the Waaler-Rose test and IgM-RF ELISA was highly significant (r = 0.82). By testing 65 of these sera (all IgM-RF positive), 25 (39%) were also true IgG-RF positive (42 (64%) in the screening). When 40 Waaler-Rose-positive RA patients were tested, 20 and 21 were also positive for IgG- and IgA-RF, respectively. Eight IgM-, one IgA- and no IgG-RF positive tests were recovered when 48 Waaler-Rose negative RA patients were studied.

Expression of rheumatoid factors in titres or units?

About 1% of the Dutch population is per year checked for the first time for the presence of rheumatoid factors (RF). Unfortunately, the interlaboratory variations of the titres of RF tests are enormous. We therefore (re)studied the effect of comparisons of the results with the WHO standard rheumatoid serum, leading to expression of the results in international units (IU), instead of in titres. Testing 5 sera in duplicate in 33 laboratories, a significant decrease of the interlaboratory variability was noted for the Waaler-Rose test, the Latex fixation test and the ELISA for the demonstration of RF's. Also the results of the antiperinuclear factor (APF) test improved significantly. The results of RF's demonstrated with the indirect immunofluorescence technique showed already a satisfactory comparability. Expression in IU's had no significant effect for this test. The introduction of the use of a reference serum met no opposition. Nearly all Dutch laboratories express now their results in units.

Immunoassay of rheumatoid factor by latex particle counting.

We assayed rheumatoid factor by instrumental latex particle counting. The calibration curve ranged from 12.5 to 500 int. units/mL. Maximal within- and between-assay CVs were 5 and 11%, respectively. Analytical recoveries ranged from 92.4 to 108%, and the relation between results and dilutions was linear in the range of 15 to 400 int. units/mL. Correlation with an enzyme-linked immunoassay (ELISA, Cordia kit) was r = 0.934 (n = 58), with turbidimetry r = 0.825 (n = 100), and with the Waaler-Rose test r = 0.834 (n = 73). Of 260 blood donors, 95% gave a value less than 10 kilo-int. units/L, which was taken as the upper normal limit. In a population of patients with rheumatoid arthritis (n = 47), 87.2% had rheumatoid factor greater than 10 kilo-int. units/L.

A seventeen-year follow-up of a population survey of rheumatoid arthritis.

A population survey was carried out in Stockholm during the period 1965-67 for the purpose of determining the prevalence of rheumatoid arthritis (RA). 239 subjects with RA were found in a random sample of 15,268. In 1983, 17 years later, all the 127 persons still living could be traced, 109 of whom were re-examined. In 95, all the information required to satisfy the New York diagnostic criteria was available, i.e. with radiographs of the hands and feet and a Waaler-Rose test. The number of subjects with involvement of at least 3 joints (criterion No. 2) had decreased from 72 to 36, while the persons with a positive Waaler-Rose test (criterion No. 3) had increased from 9 to 18. The total number of fulfilled criteria showed a reduction from a median of 2 criteria to 1. The Steinbrocker functional class remained unchanged for the group as a whole (median Class 2), with a significant deterioration only in the oldest age-group (from 2 to 3). The knee was most often the single joint in which the disease had started and also the joint which caused the subjects the most inconvenience at the follow-up. Medical records were traced for 85 of the 112 who had died. Among them, 44 cases of RA or polyarthritis were noted. The present study gives a conception of RA in the population, as well as of its development over a long span of time.

Evaluation of a quantitative immunoturbidimetric assay for rheumatoid factors.

A quantitative immunoturbidimetric assay for rheumatoid factors (RF) is described, based on the immunoprecipitation between aggregated human IgG and rheumatoid factors in serum. The resulting turbidity is measured photometrically at 340 nm. The method is standardized against the WHO international reference preparation and the results are expressed in international units per milliliter (int. units/mL). Results correlate well with those by different latex-agglutination techniques (r = 0.80-0.96). The correlation with Waaler-Rose test modifications were 0.75 and 0.92. The within-run and between-run coefficients of variations were respectively from 1.2 to 2.6% and 1.3 to 1.9% for high and low RF concentrations. Quantitative and reproducible results, together with high throughput of samples and compatibility with most clinical chemistry analyzers and photometers, make this new assay well suited for routine screening and monitoring of rheumatoid factors.

Turbidimetry of rheumatoid factor in serum with a centrifugal analyzer.

We describe the simple, rapid turbidimetry of IgM rheumatoid factor in human serum by use of the Cobas-Bio centrifugal analyzer. Heat-aggregated human IgG is used as the antigen. The immunoturbidimetric reaction is monitored at 340 nm for 300 s, and the changes in absorbance after the antigen is added are used to prepare the standard curve. Test results are calculated from the stored curve and reported in int. units/mL, based on comparison with the WHO reference serum for rheumatoid factor. There is no interference from bilirubin (up to 340 mumol/L) or hemoglobin (up to 5600 mg/L). Serum samples with a triglyceride concentration greater than 2.20 mmol/L must be cleared of lipids before analysis. The standard curve is linear from 30 to 500 int. units/mL. Precision, accuracy, linearity, and sensitivity are quite acceptable. The CV was generally less than 5% for different concentrations of rheumatoid factor. Results agree well with those by a rate-nephelometric procedure on the Beckman ICS system (rs = 0.932). However, both correlate poorly with a modified classical Waaler-Rose test. Of 47 patients with rheumatoid arthritis, 34 had IgM rheumatoid factor in their serum, but the measured value did not reflect the activity of the disease.

Demonstration of a transient rheumatoid factor in the acute phase of hepatitis non A, non B

The evaluation of an enzyme-linked immunosorbent assay (ELISA) test designed to detect antigens of hepatitis non A, non B (HNANB) revealed that a rheumatoid factor (RF)-like reaction was interfering. This RF-like reaction was not detectable by routine screening methods for RF, such as latex agglutination or the Waaler Rose test. Testing of sequential sera of chimpanzees with acute HNANB showed that this RF-like reaction was present in the acute phase of HNANB simultaneously with alanine aminotransferase (ALT) elevations. Characterization of this RF-like reaction revealed the presence of an IgM antibody against human IgG that banded in CsCl at 1.3 g/ml and at 19S in sucrose gradients. Absorption with IgG-coated latex particles and anti-human IgM gave further evidence of an RF. By testing sera of patients with different forms of acute viral hepatitis, it was demonstrated that an RF-like factor was also present in seven sera from 9 patients with acute hepatitis A, in two sera from 11 patients with hepatitis B, and seven sera from 11 patients with acute HNANB. The rise of RF in the acute phase of hepatitis A may be an effect of polyclonal stimulation of IgM producing B lymphocytes. The high prevalence of RF in HNANB remains unclear as no polyclonal stimulation of IgM has been observed.