History of ANA testing The LE cells In vitro damaged white cells are coated with “LE Factor” LE factor: a family of antibodies to nuclear constituents Late 1950’s: many in vitro immuno-fluorscence based tests developed Titers (>&=1:40 increase in specificity;patterns of immunostaining: change of substrate (Hep-2) brings >increase in sensitivity, now pos if >1:80) Change of substrate (HEp-2) Low sensitivity for anti-Ro/SSA antibodies EIA/ELISA testing=lower cost of testing, easier to perform Specific auto Abs to nuclear Ags (SSA,SSB, ds-jilDNA) Point 2

HISTORY OF ANA TESTING

When should an ANA test be ordered? When there is a clinical evaluation that has led to a presumptive diagnosis

CONDITIONS ASSOCIATED WITH POSITIVE ANA TEST Very useful –Scleroderma (60-90%),SLE (95-100%) Somewhat useful –Sjogren’s syndrome (40-70%) idiopathic inflammatory myositis (dermato/polymyositis) (30-80%)

CONDITIONS ASSOCIATED WITH+ ANA Diseases for which ANA is useful for monitoring /prognosis –Juvenile chronic oligoarticular arthritis with uveitis –Raynaud’s phenomenon Diseases for which a positive ANA test is an intrinsic part of diagnostic criteria –Drug-induced SLE –MCTD

Titer significance > 1: 40 = NEGATIVE > 1: 80 – 1: 160 = low titer positive > 1: 160 = positive, more likely to have autoimmune disease

Diseases for which an ANA test is NOT useful in diagnosis Rheumatoid arthritis 30-50% Multiple sclerosis 10-30% Thyroid disease 30-50% Discoid lupus 5-25% Infectious diseases wide variations Malignancies wide variations Patients with silicone breast implants 15-25% Fibromyalgia 15-25% Healthy relatives of pts with SLE or Scleroderma 5-25%

Conditions with +ANA Autoimmune disease Infectious disease Medications Epidemiology Conditions Very High Titers: more likely to have autoimmune disease, but does NOT indicate disease activity

ANA Patterns Homogenous chromatin (but homogenous histone is drug related) Rim pattern (chromatin 1013& nuclear membrane) Fine speckled (nuclear RNP & chromatin..but more common in other CTD)

ANA PATTERNS & ASSOCIATIONS Homogenous Pattern-also present in % of SLE Anti-Histone: Drug SLE

Nuclear RNP Specific for MCTD (100)% of pts with MCTD) Also present in 30-40% of SLE Assoc with MCTD, overlap SLE, and also DM/PM, and Scleroderma

Speckled CREST syndrome (CREST has speckles in the center) Anti-Centromere present in 70-85% of pts with limited scleroderma/CREST Anti-centromere present in <5% of SLE Associated with Raynaud’s phenomena

CYTOPLASMIC/ANTI RIBOSOMAL Psychiatric Lupus

AUTOANTIBODY ASSOCIATIONS ANA is sensitive Anti-Sm and DS-DNA are specific ANA in a primary care setting: Sensitivity=100%,Specificity=67% Negative ANA is useful, however +ANA present in many DX and in normals(5- 40%)

Autoantibody specificity: Specific for SLE Anti SM ( RNP) Present in 30-40% of SLE Very uncommon in other diseases Associated with Interstitial Lung Disease Specificity: Sjogen’s (60-70% of pts with Sjogren’s)

Ro(SSA) and La (SSB). Ro present in 25-30% of SLE, La also present in 10-15% of SLE Also associated with subacute cutaneous lupus Anti-Ro (NOT La): Neonatal lupus with heart block (babies drown from Ro boats)

ANTI-JO-1 Specificity: present in 40-50% of pts with Polymyositis/Dermatomyositis, especially with pulmonary interstitial disease & arthritis Present in < 5% of SLE

SCL-70 (topoismerase 1) PSS (Progressive Systemic Sclerosis) (40-70% of pts with Diffuse PSS)

When should an ANA test be ordered? When there is a clinical evaluation that has led to a presumptive diagnosis

ANA :FAQs What tests should be performed in young women with symmetric arthralgias? A) arthralgias (not arthritis), 6weeks- NOTHING,CMV,HSV,VZV VIRUSES frequently-HBV,HAV, HCV< rubella(vaccine as well), parvo, occasionally, EBV,HIV,mumps,coxsackie,echo,adeno,CMV HSV, VZV

ANA: FAQs B) arthralgias > 6 weeks or Arthritis- Further investigation

ANA : FAQs What other testing should be done after a + ANA in an asymptomatic patient? NOTHING more……Consider following for 3-5 years? What tests should be done in young women with symmetric arthralgias? A) arthralgias (not arthritis) < 6 wks- NOTHING Viruses frequently, HBV, HCV,rubella (vaccine), parvo, occasionally-EBV,HIV, mumps,

RAMIFICATIONS OF + ANA Patients spend the rest of their lives waiting to get sick, still think they are sick, request disability in the absence of any rheumatological disease findings, one person telling them a +ANA implies Lupus seems to outweigh several people telling them there is nothing wrong with them, all symptoms they have the rest of their lives are due “to my Lupus”, which they don’t have