IMMUNOPATHOLOGY
Special Article
Practice Parameter—The Lupus
Erythematosus Cell Test
An Obsolete Test Now Superseded by Definitive
Immunologic Tests
REX B. CONN, MD
The lupus erythematosus (LE) cell test (synonyms: LE prep, LE phe-
nomenon; CPT No. 85544, LE Cell Prep) is a diagnostic test for sys-
temic lupus erythematosus (SLE) that is based on an in vitro immuno-
logic reaction between the patient's autoantibodies to nuclear antigens
and damaged nuclei in the testing medium. It is subject to numerous
The "lupus erythematosus (LE) cell" was first described by
Hargraves and coworkers,1 in 1948, and early publications on
this topic referred to the "Hargraves' cell." Before introduction
of the LE cell test, systemic lupus erythematosus (SLE) was a
clinical diagnosis, and the disorder was not recognized in many
patients.2 Perhaps equally important as the diagnostic useful-
From the Department ofPathology and Cell Biology, Jefferson Medi- tions, such as rheumatoid arthritis, "collagen" diseases, and
cal College of Thomas Jefferson University, Philadelphia. Pennsyl- drug reactions, might have a false-positive test.2 Nevertheless,
vania.
Manuscript received July 6, 1993; revision accepted August 20,
1993.
Address reprint requests to Dr. Conn: Pavilion 204, Thomas Jeffer-
son University Hospital, 125 South 11th Street, Philadelphia, PA
19107.
Disclaimer: This practice parameter represents the opinions and rec-
ommendations of the author(s), the ASCP Practice Parameters Com-
mittee, and the ASCP Board of Directors regarding the appropriate
strategies for each clinical condition or laboratory test discussed in this time, is of little or no use in monitoring the effects of treat-
parameter. This practice parameter is designed primarily as an educa-
tional resource for physicians to help them provide quality medical
services.
Adherence to this practice parameter is completely voluntary and
does not necessarily assure a successful medical treatment or result.
This practice parameter should not be considered inclusive of all
proper procedures and tests or exclusive of other procedures and tests
that are reasonably directed to obtaining the same results. The physi-
cian should apply his or her own professional judgment to the unique
clinical circumstances presented by the particular patient or specimen
in determining the propriety of any specific procedure or test.
Physicians are encouraged to document the reasons for whatever
procedure or test they use (whether or not in conformance with this
parameter). Physicians should also take care to consider other medical
and scientific advances that are available after the date of adoption of
this practice parameter.
This practice parameter was developed exclusively for the purposes
set forth above and not for use in connection with matters involving
reimbursement, credentialing, or utilization review.
65
experimental variables and dependent on subjective interpretation. It
should be abandoned in favor of more definitive, quantitative immuno-
logic tests for this condition. (Key words: Antinuclear antibodies; LE
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cell test; Lupus erythematosus; Practice parameter) Am J Clin Pathol
1994;101:65-66.
ness of the LE cell test was the fact that it stimulated basic
research on SLE and related immune-mediated diseases.
Systemic lupus erythematosus is a multisystem disorder that
may present with myriad confusing signs and symptoms, and a
laboratory test to support a clinical diagnosis was welcomed by
all diagnosticians. It soon became apparent that not all patients
with SLE had a positive LE cell test; most investigators found a
positive test in approximately 80% of patients with active dis-
ease.3 It also became apparent that patients with other condi-
the LE cell test remained a useful laboratory procedure until
more definitive tests became available.
None of the numerous investigations of the LE cell test has
demonstrated any relationship between the results of the test
and activity of the disease. Results are not quantitative; the
report is either positive or negative. Patients with SLE in remis-
sion may have a positive test, and some with active disease may
have a negative test. The result, or the change in result over
ment.2 Demonstration of a positive LE cell test depends on the
technique used, the frequency with which it is done, and the
time during which the patient is studied. One patient with clini-
cally typical SLE is reported to have had 44 LE cell tests over a
period of 10 years before the first positive result was obtained.2
Introduction of the fluorescent antinuclear antibody test in
the 1960s led to extensive investigations comparing the LE cell
test with the fluorescent antinuclear antibody test. With
current techniques, thefluorescentantinuclear antibody test is
positive in more than 98% of patients with active SLE. As early
as 1969, Barnett and Rothfield3 stated: "The indirect immuno-
fluorescent technique for antinuclear antibodies, when 'prop-
erly performed,' would be positive in nearly every case where
the LE cell phenomenon is positive." Definitive studies showed
that false-positive LE cell tests occurred for several reasons,
primarily misinterpretation of cellular morphology on micro-
scopic examination.2 As a result of these problems, diagnostic
66 IMMUNOPATHOLOGY
Special Article
use of the LE cell test has waned, and interest in conducting
further studies disappeared. The Medline files list only nine
articles published since 1987 in which LE cells were a focus
topic; in eight they were an incidental finding or not the main
topic. The ninth article is an editorial asking, "Should we still
do research on the LE cell?"4
TECHNIQUE
The LE phenomenon is an in vitro test that identifies poorly
characterized antibodies to poorly characterized nuclear anti-
gens. The phenomenon requires nuclei from damaged leuko-
cytes, viable cells capable of phagocytosis, complement, and
the LE factor. The latter is a complement-fixing IgG antideoxy-
ribonucleoprotein antibody, but the exact antigens involved
remain unknown. The LE factor is not species specific, and
leukocytes from several species have been used as the phago-
cytic cells and as the nuclear substrate.
Various refinements have been made in the technique used
to produce LE cells. A popular method uses heparinized blood
rotated in a tube containing glass beads followed by centrifuga-
tion and preparation of slides from the buffy coat. In another
method, the patient's blood is allowed to clot for 2 hours at
room temperature or at 37 °C. The clotted blood is forced
through afine-meshwire screen, and the filtrate is centrifuged.
The buffy coat is smeared on several microscope slides and
stained with Wright's stain. In yet another method, the cells of
the buffy coat are "washed" with patient's serum. In one study
of 790 split samples using two different techniques, positive
and negative results were inconsistent between the two
methods.2
The slides must be carefully examined for LE cells. These are
phagocytic cells, mostly polymorphonuclear neutrophils but
occasionally monocytes, that have ingested damaged nuclei,
resulting in displacement of the nuclei of the phagocytes to the
periphery of the cytoplasm. The ingested nuclei are swollen,
homogeneous, pink-staining masses. This appearance is due to
presence of the LE factor. A major interpretive difficulty arises
because bare nuclei are ingested by phagocytic cells in the ab-
sence of the LE factor. The ingested material is a varying shade
of blue, and vestiges of the chromatin pattern remain. The
latter cells are called tart cells, after the surname of the patient
in whom they were first found. The distinction between LE
cells, tart cells, and a third variety known as "pseudo-LE cells"
rests on subjective judgment that may be influenced by prior
knowledge of the patient's diagnosis or symptoms.
An important consideration regarding the LE cell test is its
cost. In addition to the time-consuming preparative steps, ac-
ceptable technique requires a medical technologist to spend
10-15 minutes for microscopic examination of at least two
slides.
It is rare to find LE cells in vivo except in closed spaces, such
as the synovial, pleural or, pericardial cavities. If an effusion
contains the LE factor, damaged leukocytes, viable phagocytes,
and complement, LE cells may be formed. If LE cells are noted
in an effusion, and can be distinguished from tart and pseudo-
LE cells, a diagnosis of SLE, which had not been made previ-
ously, should be ascribed to serendipity. The cells seen in such
effusions are usually reported as "cells consistent with LE
cells."
A.J.C.P.-January 1994
WHICH TESTS TO USE
Currently available fluorescent antinuclear antibody tests or
immunoenzyme tests (immunoperoxidase) have replaced the
LE cell test in virtually all laboratories in the United States
because of their high diagnostic sensitivity. Current research is
defining the diagnostic sensitivity and specificity of the tests
when different substrates are used: cryostat sections of liver,
kidney, or heart; nonmammalian cells, such as Crithidia luci-
liae; or human cells in culture (Hep-2). More specific tests are
available or under development. The Sm (for Smith) antibody
test is specific for SLE; however, it is positive in only 29% of
patients with active SLE.5 Tests for antibodies to double
stranded DNA (anti-dsDNA) may be the most useful single test
in diagnosing and monitoring SLE. It is highly sensitive, pro-
vides quantitative data, may help in assessing disease activity,
and, when present in high titer, is specific for SLE.6"8 The speci-
ficity of the antibody can be evaluated with other tests, such as
immunodiffusion, hemagglutination, immunoblotting, and
immunoenzyme procedures.9
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PREPARATION OF THIS REPORT
This report was prepared by the Practice Parameters/Out-
come Measurement Committee of the American Society of
Clinical Pathologists (ASCP) and was reviewed by the ASCP
Council on Immunopathology, which is composed of leading
authorities in this field. The report was also reviewed by the
Committee on Health Care Research of the American College
of Rheumatology. A Medline search from 1948 to date was
conducted, and the relevant articles were reviewed. The Prac-
tice Parameter was approved by the ASCP Board of Directors
at its meeting of March 27, 1993.
REFERENCES
1. Hargraves MM, Richmond H, Morton R. Presentation of two
bone marrow elements: The "Tart" cell and the "LE cell." Proc
Staff Mayo Clin 1948;23:25-28.
2. Dubois EL. Current status of the LE cell test. Semin Arthritis
Rheum 1971; 1:97-115.
3. Barnett EV, Rothfield N. The present status of antinuclear anti-
body serology. Arthritis Rheum 1969; 12:543-544.
4. Kahn NF. Should we still do research on the LE cell? (editorial).
Rev Med Interne 1987;8:149-151.
5. Tsay GJ, Chan EK, Peebles CL, et al. An immunoassay differen-
tiating sera with antibodies to Sm alone, antibodies to Sm/RNP
complex, and antibodies to RNP alone. Arthritis Rheum
1987; 30:389-396.
6. Swaak AJG, Groenwold J, Bronsveld W. Predictive value of com-
plement profiles and anti-dsDNA in systemic lupus erythema-
tosus. Ann Rheum Dis 1986,45:359-366.
7. ter Borg EJ, Horst G, Hummel EJ, et al. Measurement of increases
in anti-double stranded DNA antibody levels as a predictor of
disease exacerbation in systemic lupus erythematosus. A long-
term prospective study. Arthritis Rheum 1990;33:634-643.
8. Nakamura RM, Tan EM. Recent advances in laboratory tests and
the significance of autoantibodies to nuclear antigens in sys-
temic rheumatic diseases. Clin Lab Med 1986;6:41-53.
9. Tan EM. Antinuclear antibodies: Diagnostic markers for autoim-
mune diseases and probes for cell biology. Adv Immunol
1989;44:93-15I.