Common Rheumatologic Tests: Common Rheumatologic Tests:

Evaluation and !nterpretation Evaluation and !nterpretation

Beth valashinas, D.O. Beth valashinas, D.O.
Chief Rheumatology Fellow Chief Rheumatology Fellow
University of North Texas Health University of North Texas Health
Science Center/ Plaza Nedical Center Science Center/ Plaza Nedical Center
Disclosures Disclosures
- - Nothing to disclose Nothing to disclose
!ntroduction !ntroduction
- - !mmunologic laboratory testing in !mmunologic laboratory testing in
rheumatology is useful for supporting or rheumatology is useful for supporting or
refuting a clinically suspected diagnosis refuting a clinically suspected diagnosis
- - Shotgun approaches" or screening Shotgun approaches" or screening
tests" often lead to false positives, and tests" often lead to false positives, and
further unnecessary workups/referrals further unnecessary workups/referrals
Background Background
- - Defining attributes of a test Defining attributes of a test
-- Sensitivity Sensitivity
-- Specificity Specificity
-- Positive predictive value Positive predictive value
-- Negative predictive value Negative predictive value
-- Likelihood ratios Likelihood ratios
-- Pretest and posttest probabilities Pretest and posttest probabilities
ttributes of a test ttributes of a test
- - Sensitivity Sensitivity
-- Proportion of patients with a disease who Proportion of patients with a disease who
have a positive test result have a positive test result
- - Specificity Specificity
-- Proportion of patients without a disease who Proportion of patients without a disease who
have a negative test result have a negative test result
- - Both sensitivity and specificity are Both sensitivity and specificity are
independent of disease prevalence independent of disease prevalence
ttributes of a test ttributes of a test
- - Predictive value Predictive value
-- likelihood of disease or lack thereof based on likelihood of disease or lack thereof based on
a positive or negative test result a positive or negative test result
-- Negative predictive value (NPv) Negative predictive value (NPv)
- - True negative/(true negative + false negative) True negative/(true negative + false negative)
-- Positive predictive value (PPv) Positive predictive value (PPv)
- - True positive/(true positive + false positive) True positive/(true positive + false positive)
Predictive value Predictive value
- - Predictive value is significantly affected by Predictive value is significantly affected by
disease prevalence disease prevalence
-- Predictive value of a positive rheumatologic Predictive value of a positive rheumatologic
test in patient with polyarthralgias is likely to test in patient with polyarthralgias is likely to
be higher in a rheumatology practice than in a be higher in a rheumatology practice than in a
family physician's office family physician's office
-- s pretest probability increases, so does the s pretest probability increases, so does the
clinical utility of a specific test clinical utility of a specific test
Lane, SK and Cravel, ]R. merican Family Physician. 6S,6,1073,2002.
ttributes of a test ttributes of a test
- - Likelihood ratio Likelihood ratio
-- LR for a negative test result: LR for a negative test result:
(1 (1sensitivity)/specificity sensitivity)/specificity
-- LR for a positive test result: LR for a positive test result:
sensitivity/(1 sensitivity/(1specificity) specificity)
Likelihood ratio Likelihood ratio
- - Provides additional measure by allowing Provides additional measure by allowing
calculation of posttest probability based on calculation of posttest probability based on
pretest probability and test result pretest probability and test result
- - Decision to use a test should be based Decision to use a test should be based
upon whether posttest probability will be upon whether posttest probability will be
significantly different from the pretest significantly different from the pretest
probability given a positive or negative probability given a positive or negative
test result test result
CR D HOC Committee. rthritis Care and Research. 47:423, 2002.
ttributes of a test ttributes of a test
- - !f a test has a high positive likelihood ratio !f a test has a high positive likelihood ratio
(e.g., 10), and the test result is positive, (e.g., 10), and the test result is positive,
then the posttest probability of the test then the posttest probability of the test
will be greatly increased will be greatly increased
- - !f the likelihood ratio is only 1, then no !f the likelihood ratio is only 1, then no
difference would be expected between difference would be expected between
pretest and posttest probabilities pretest and posttest probabilities
Performance characteristics of Performance characteristics of
specific Ns specific Ns
ntigen ntigen Condition Condition Sensitivity Sensitivity Specificity Specificity + LR + LR LR LR
nti ntidsDN dsDN
b b
SLE SLE S7% S7% 37% 37% 16.3 16.3 0.43 0.43
nti ntiSm b Sm b SLE SLE 2S 2S30% 30% high high ** **
nti ntiRo/SS Ro/SS
b b
Sjogren's, Sjogren's,
SCLE SCLE
8870% 70% 87% 87% ** **
nti ntiLa/SSB La/SSB
b b
Sjogren's, Sjogren's,
SCLE SCLE
16 1640% 40% 34% 34% ** **
Scl Scl70 70 Scleroderma Scleroderma 20% 20% 100% 100% >2S >2S 0.8 0.8
nticentrome nticentrome CREST CREST 6S% 6S% 33.3% 33.3% 6S0 6S0 0.4 0.4
nti ntiUU3 RNP 3 RNP Scleroderma Scleroderma 12% 12% 36% 36% 33 0.32 0.32
Colglazier, CL et al. Southern Nedical ]ournal.200S
cute phase reactants cute phase reactants
- - Heterogeneous group of proteins Heterogeneous group of proteins
synthesized in liver in response to synthesized in liver in response to
inflammation inflammation
-- Fibrinogen Fibrinogen
-- Haptoglobin Haptoglobin
-- C Creactive protein reactive protein
-- lpha lpha11antitrypsin antitrypsin
cute phase protein response cute phase protein response
dapted from Citlin ]D, Colten HR in Pick E, Landy N |eds]: Lymphokines.14,123,1387.
Common markers of inflammation Common markers of inflammation
- - ESR ESR
-- Neasures distance (in mm) that RBCs fall Neasures distance (in mm) that RBCs fall
within specified tube (Westergren or within specified tube (Westergren or
Wintrobe) over 1 hour Wintrobe) over 1 hour
-- !ndirect measure of changes in acute !ndirect measure of changes in acutephase phase
reactants and quantitative !gs reactants and quantitative !gs
-- Decreases by ~S0% in 1 week after Decreases by ~S0% in 1 week after
inflammation resolves inflammation resolves
Nechanism of elevated ESR Nechanism of elevated ESR
- - !f higher concentration of asymmetrically !f higher concentration of asymmetrically
charged acute charged acutephase protein or phase protein or
hypergammaglobulinemia occurs, hypergammaglobulinemia occurs,
dielectric constant of plasma increases and dielectric constant of plasma increases and
dissipates inter dissipates interRBC repulsive forces, leads RBC repulsive forces, leads
to closer aggregation of RBCs, so they fall to closer aggregation of RBCs, so they fall
faster, and cause ESR elevation faster, and cause ESR elevation
Hobbs, K in West, S. Rheumatology Secrets,2002
Noninflammatory conditions with Noninflammatory conditions with
elevated ESR elevated ESR
- - ging ging
- - Female sex Female sex
- - Obesity Obesity
- - Pregnancy Pregnancy
Rule of thumb Rule of thumb
- - ge geadjusted upper limit normal for ESR adjusted upper limit normal for ESR
-- Nale: age/2 Nale: age/2
-- Female: (age + 10)/2 Female: (age + 10)/2
Causes of markedly elevated ESR Causes of markedly elevated ESR
- - ESR >100 ESR >100
-- !nfection, bacterial (3S%) !nfection, bacterial (3S%)
-- CTD (CC, PNR, SLE, vasculitides (2S%) CTD (CC, PNR, SLE, vasculitides (2S%)
-- Nalignancy: lymphomas, myeloma, etc (1S%) Nalignancy: lymphomas, myeloma, etc (1S%)
-- Other causes (2S%) Other causes (2S%)
Hobbs, K in West, S. Rheumatology Secrets,2002.
Causes of extremely low ESR Causes of extremely low ESR
- - ESR ~ 0mm/hr ESR ~ 0mm/hr
-- gammaglobulinemia gammaglobulinemia
-- fibrinogenemia/dysfibrinogemia fibrinogenemia/dysfibrinogemia
-- Extreme polycythemia (Hematocrit >6S%) Extreme polycythemia (Hematocrit >6S%)
-- !ncreased plasma viscosity !ncreased plasma viscosity
pproach to elevated ESR pproach to elevated ESR
- - Complete HSP Complete HSP
- - Routine labs (CBC, CNP, U) Routine labs (CBC, CNP, U)
- - Up Upto todate cancer screening/health date cancer screening/health
maintenance maintenance
- - Repeat ESR Repeat ESR
- - !f still elevated without other association !f still elevated without other association
-- Consider SPEP, CRP Consider SPEP, CRP
-- Recheck in 1 Recheck in 13 months (up to 80% normalize) 3 months (up to 80% normalize)
C Creactive protein (CRP) reactive protein (CRP)
- - Pentameric protein Pentameric protein
-- Trace concentrations in human plasma Trace concentrations in human plasma
-- Highly conserved over hundreds of millions of Highly conserved over hundreds of millions of
years of evolution years of evolution
-- Properties of recognition and activation Properties of recognition and activation
- - ctivates classic complement pathway ctivates classic complement pathway
- - Nodulates behavior of phagocytic cells (both Nodulates behavior of phagocytic cells (both
inflammatory and non inflammatory and noninflammatory influence) inflammatory influence)
CRP CRP
- - cute phase reactant produced by liver cute phase reactant produced by liver
-- Response to !L Response to !L6, other cytokines 6, other cytokines
- - Rises and falls quickly Rises and falls quickly
-- Elevation within 4 hr of tissue injury Elevation within 4 hr of tissue injury
-- Peak at 24 Peak at 2472 hr 72 hr
-- Half Halflife ~18 hr life ~18 hr
Rule of thumb Rule of thumb
- - CRP <0.2 mg/dL: normal CRP <0.2 mg/dL: normal
- - CRP 0.2 CRP 0.21.0 mg/dL: indeterminate (may 1.0 mg/dL: indeterminate (may
be seen in smoking, DN) be seen in smoking, DN)
- - CRP >1.0 mg/dL: inflammatory CRP >1.0 mg/dL: inflammatory
- - Levels > 10mg/dL suggest bacterial Levels > 10mg/dL suggest bacterial
infection (up to 8S%), or possibly infection (up to 8S%), or possibly
systemic vasculitis, metastatic cancer systemic vasculitis, metastatic cancer
Norely ]], et al. nn N Y cad Sci,383,1382.
Serum protein electrophoresis Serum protein electrophoresis
(SPEP) (SPEP)
- - Ouantifies the acute Ouantifies the acutephase response phase response
-- !ncrease in alpha !ncrease in alpha1 and 1 and 2 zones (alpha 2 zones (alpha1 1
antitrypsin and haptoglobin) antitrypsin and haptoglobin)
-- !ncrease in beta !ncrease in betagamma area (fibrinogen and gamma area (fibrinogen and
CRP) CRP)
-- Decrease in pre Decrease in prealbumin, albumin, and the albumin, albumin, and the
beta zone (transferrin) beta zone (transferrin)
Normal SPEP Normal SPEP
erl.pathology.iupui.edu/LBNED/!NCES/SPE_16.]PC
SPEP SPEP acute inflammation acute inflammation
erl.pathology.iupui.edu/LBNED/!NCES/SPE_16.]PC
SPEP SPEP Polyclonal gammopathy Polyclonal gammopathy
erl.pathology.iupui.edu/LBNED/!NCES/SPE_16.]PC
ntinuclear antibodies (N) ntinuclear antibodies (N)
- - !nitial LE test in 1340s !nitial LE test in 1340s
-- !ncubate bare nucleus with pt's serum, !ncubate bare nucleus with pt's serum,
allowing Ns to bind to nucleus allowing Ns to bind to nucleus
-- Then add normal PNNs and if sufficient b Then add normal PNNs and if sufficient b
have bound to nucleus, nucleus is opsonized have bound to nucleus, nucleus is opsonized
and PNNs engulf the material and PNNs engulf the material
-- LE cell is PNN containing phagocytosed LE cell is PNN containing phagocytosed
nucleus nucleus
LE Cell LE Cell
Current N measurement Current N measurement
- - Fluorescence microscopy Fluorescence microscopy
-- HEp HEp2 cells (derived from human epithelial 2 cells (derived from human epithelial
tumor cell line) incubated with pt's serum tumor cell line) incubated with pt's serum
-- Fluoresceinated b added, binds to pt's bs Fluoresceinated b added, binds to pt's bs
bound to nucleus bound to nucleus
-- mount of N determined by dilution of the mount of N determined by dilution of the
pt's serum pt's serum the greater the dilution (titer) at the greater the dilution (titer) at
which nuclear fluorescence detected, the which nuclear fluorescence detected, the
higher the N concentration higher the N concentration
N N
- - rbitrary definition of positive N is the rbitrary definition of positive N is the
level that exceeds that seen in 3S% of the level that exceeds that seen in 3S% of the
population population
- - Titers usually positive" at 1:40 to 1:80 Titers usually positive" at 1:40 to 1:80
- - Clinically significant titers (with HEp Clinically significant titers (with HEp2 2
cells) ~1:160 cells) ~1:160
N N
- - High sensitivity in SLE, but poor specificity High sensitivity in SLE, but poor specificity
- - Positive N has predictive value of only Positive N has predictive value of only
11% (positive LR =2.2) 11% (positive LR =2.2)
- - N found in S N found in S10% of pts without CTD 10% of pts without CTD
-- Healthy pts, chronic infections (e.g., Hep C), Healthy pts, chronic infections (e.g., Hep C),
multiple meds, etc. multiple meds, etc.
N N
- - Condition Condition
-- SLE SLE
-- Drug induced lupus Drug induced lupus
-- NCTD NCTD
-- utoimmune liver dz utoimmune liver dz
-- Sjogren's syndrome Sjogren's syndrome
-- Polymyositis Polymyositis
-- R R
- - % N % Npositive positive
-- 33% 33%
-- 3S 3S100% 100%
-- 3S 3S100% 100%
-- 60 60100% 100%
-- 7S 7S30% 30%
-- 30 3080% 80%
-- 30 30S0% S0%
dapted from Hobbs, K in West, S Rheumatology Secrets, 2002.
N N
- - Condition Condition
-- Nultiple sclerosis Nultiple sclerosis
-- Pts with silicone breast Pts with silicone breast
implants implants
-- Healthy relatives of pts Healthy relatives of pts
with SLE with SLE
-- Neoplasms Neoplasms
-- Normal elderly (>70 Normal elderly (>70
yrs) yrs)
- - % N % Npositive positive
-- 2S% 2S%
-- 1S 1S2S% 2S%
-- 20% 20%
dapted from Hobbs, K in West, S. Rheumatology Secrets, 2002
N N
- - !s the N a good screening test for SLE? !s the N a good screening test for SLE?
-- !f >S% of normal U.S. population has positive !f >S% of normal U.S. population has positive
N, then over 12.S million normal" people N, then over 12.S million normal" people
in U.S. are N positive in U.S. are N positive
-- Prevalence of SLE is only ~1/1000, so only Prevalence of SLE is only ~1/1000, so only
2S0,000 individuals with SLE and positive N 2S0,000 individuals with SLE and positive N
-- !f entire population was screened, more !f entire population was screened, more
normal individuals would be detected with normal individuals would be detected with
positive N than SLE pts. by ~S0:1 positive N than SLE pts. by ~S0:1
Hobbs, K. in West, S Rheumatology Secrets. 2002..
N N
- - Clinical value of ordering an N test can Clinical value of ordering an N test can
be dramatically enhanced when there is a be dramatically enhanced when there is a
reasonable pre reasonable pretest probability of an test probability of an
autoimmune disease autoimmune disease
N patterns N patterns
- - Homogeneous (diffuse) Homogeneous (diffuse)
-- SLE, drug SLE, druginduced SLE, other diseases induced SLE, other diseases
N patterns N patterns
- - Rim (peripheral) Rim (peripheral)
-- SLE, autoimmune hepatitis SLE, autoimmune hepatitis
N patterns N patterns
- - Speckled Speckled
-- SLE, NCTD, Sjogren's, Scleroderma, other dz SLE, NCTD, Sjogren's, Scleroderma, other dz
N patterns N patterns
- - Nucleolar Nucleolar
-- Scleroderma, hepatocellular carcinoma Scleroderma, hepatocellular carcinoma
N patterns N patterns
- - Centromere Centromere
-- Limited scleroderma (CREST) Limited scleroderma (CREST)
Drug Druginduced Ns induced Ns
- - Common drugs that cause positive Ns Common drugs that cause positive Ns
-- Procainamide Procainamide
-- Hydralazine Hydralazine
-- Phenothiazines Phenothiazines
-- Diphenylhydantoin Diphenylhydantoin
-- !soniazid !soniazid
-- Ouinidine Ouinidine
Lupus or N profile Lupus or N profile
- - !f screening N is positive and additional !f screening N is positive and additional
info needed to further delineate type of info needed to further delineate type of
autoimmune disease autoimmune disease
- - !n extremely rare instances, N may be !n extremely rare instances, N may be
negative but SS negative but SS antibodies may be antibodies may be
detected in pts. with an SS detected in pts. with an SS associated associated
disease disease
Lupus Profile Lupus Profile
dsDN dsDN RNP RNP SN SN SS SS SS SSBB CENTRONERE CENTRONERE
SLE SLE 60% 60% 30% 30% 30% 30% 30% 30% 1S% 1S% Rare Rare
R R (()) (()) (()) Rare Rare Rare Rare (())
NCTD NCTD (()) >3S% >3S% (()) Rare Rare Rare Rare Rare Rare
Scleroderma Scleroderma (()) Low Low
titer titer
(()) Rare Rare Rare Rare 10 101S% 1S%
CREST CREST (()) (()) (()) (()) (()) 60 6030% 30%
Sjogren's Sjogren's (()) Rare Rare (()) 70% 70% 60% 60% (())
Hobbs, K. in West, S Rheumatology Secrets. 2002.
Lupus Profile Lupus Profile
- - ntibodies to dsDN are associated with lupus ntibodies to dsDN are associated with lupus
nephritis, and often parallel disease activity nephritis, and often parallel disease activity
- - ntibodies to SS ntibodies to SS/Ro and SS /Ro and SSB/La are B/La are
commonly associated with Sjogren's syndrome commonly associated with Sjogren's syndrome
- - nti ntiRo/SS antibodies increase risk for neonatal Ro/SS antibodies increase risk for neonatal
lupus/congenital heart block (CHB), especially lupus/congenital heart block (CHB), especially
when in conjunction with anti when in conjunction with antiLa/SSB b La/SSB b
-- Overall risk is ~S% Overall risk is ~S%
ntibodies to ribonuclear protein ntibodies to ribonuclear protein
(RNP) (RNP)
- - Target is spliceosomal snRNPs in Target is spliceosomal snRNPs in
nucleoplasm nucleoplasm
- - Seen in SLE, scleroderma, mixed Seen in SLE, scleroderma, mixed
connective tissue disease (NCTD) connective tissue disease (NCTD)
- - High levels very suggestive of NCTD High levels very suggestive of NCTD
-- NCTD is overlap disease with features of SLE, NCTD is overlap disease with features of SLE,
scleroderma, and polymyositis scleroderma, and polymyositis
nticentromere and SCL nticentromere and SCL70 b 70 b
- - nticentromere b nticentromere b
-- up to 38% pts with limited scleroderma up to 38% pts with limited scleroderma
(CREST) (CREST)
-- 22 2236% pts with diffuse scleroderma 36% pts with diffuse scleroderma
- - nti ntiSLC70 (anti SLC70 (antitopoisomerase !) topoisomerase !)
-- 22 2240% pts with diffuse scleroderma 40% pts with diffuse scleroderma
- - longer disease duration, association with cancer, longer disease duration, association with cancer,
pulmonary fibrosis, digital pitting scars, cardiac pulmonary fibrosis, digital pitting scars, cardiac
manifestations manifestations
nti ntidsDN b prior to Dx of SLE dsDN b prior to Dx of SLE
- - Serum from 130 SLE patients Serum from 130 SLE patients
-- SS% had anti SS% had antidsDN b prior to SLE Dx dsDN b prior to SLE Dx
-- Nean onset of b 2.7 years prior to Dx Nean onset of b 2.7 years prior to Dx
(range <1mo (range <1mo3.3 years) 3.3 years)
-- S8% of cases with at least 2 positive samples S8% of cases with at least 2 positive samples
had significant rise in anti had significant rise in antidsDN within 6 dsDN within 6
months of Dx months of Dx
N. R. rbuckle, et al. Scandinavian ]ournal of !mmunology S4 (12) , 211-213.
Evaluation of pt with positive N Evaluation of pt with positive N
and generalized arthralgias and generalized arthralgias
- - H S P H S P any signs of CTD? any signs of CTD?
- - !f N titer !f N titer 1:160, consider lupus 1:160, consider lupus
profile profile
- - Other possible tests: CBC, CNP, C3, C4, Other possible tests: CBC, CNP, C3, C4,
SPEP, RF, ESR, U, lupus anticoagulant, SPEP, RF, ESR, U, lupus anticoagulant,
anticardiolipin antibody anticardiolipin antibody
ntiphospholipid antibodies ntiphospholipid antibodies
- - Heterogeneous group of b that bind to Heterogeneous group of b that bind to
plasma proteins, have affinity for plasma proteins, have affinity for
phospholipid surfaces phospholipid surfaces
-- nticardiolipin b (CL) nticardiolipin b (CL)
-- Lupus anticoagulant (LC) Lupus anticoagulant (LC)
-- Beta 2 Beta 2glycoprotein ! glycoprotein !
ntiphospholipid antibodies ntiphospholipid antibodies
- - CL measured by EL!S assay for !gC, CL measured by EL!S assay for !gC,
!gN, and !g isotypes !gN, and !g isotypes
- - LC measured by phospholipid LC measured by phospholipiddependent dependent
screening test, if prolonged, add 1:1 mix screening test, if prolonged, add 1:1 mix
with normal plasma with normal plasma if no correction, LC if no correction, LC
present present
- - Beta 2 Beta 2glycoprotein ! measured by EL!S glycoprotein ! measured by EL!S
ntiphospholipid antibodies ntiphospholipid antibodies
- - Conditions with positive aPL Conditions with positive aPL
-- ~8% normal population ~8% normal population
-- chronic infections e.g., H!v, Hep C chronic infections e.g., H!v, Hep C
-- Nedications e.g., phenothiazines, hydralazine, Nedications e.g., phenothiazines, hydralazine,
phenytoin, procainamide, quinidine phenytoin, procainamide, quinidine
-- ~20% pts. with systemic vasculitis ~20% pts. with systemic vasculitis
-- ~1S% pts. with recurrent miscarriage ~1S% pts. with recurrent miscarriage
-- ~S0% pts. with SLE ~S0% pts. with SLE
Hansen, KE. in West, S Rheumatology Secrets, 2002.
ntiphospholipid antibodies ntiphospholipid antibodies
- - ~S0% pts. with SLE and aPL will develop ~S0% pts. with SLE and aPL will develop
a thrombotic event a thrombotic event
- - ~3 ~37% pts. per year who have aPL will 7% pts. per year who have aPL will
experience a new thrombotic event experience a new thrombotic event
- - Overall positive predictive value of an aPL Overall positive predictive value of an aPL
for future Cv, venous thrombosis, or for future Cv, venous thrombosis, or
recurrent NC is between 10 recurrent NC is between 102S% 2S%
Hansen, KE. in West, S. Rheumatology Secrets, 2002.
Cryoglobulins Cryoglobulins
- - !mmunoglobulins that precipitate in cold !mmunoglobulins that precipitate in cold
temperatures temperatures
- - Nay cause hyperviscosity or vasculitis Nay cause hyperviscosity or vasculitis
- - Symptoms include fatigue, Symptoms include fatigue,
arthralgias/arthritis, cutaneous vasculitis arthralgias/arthritis, cutaneous vasculitis
or purpura, neuropathies, visceral organ or purpura, neuropathies, visceral organ
involvement, and digital ischemia involvement, and digital ischemia
Cryoglobulins Cryoglobulins
- - Type ! Type ! Nonoclonal !g (!gC or !gN) Nonoclonal !g (!gC or !gN)
-- Lymphoproliferative disorders Lymphoproliferative disorders
- - Type !! Type !! Nonoclonal !gN directed against Nonoclonal !gN directed against
polyclonal !gC polyclonal !gC
-- Najority associated with Hepatitis C Najority associated with Hepatitis C
- - Type !!! Type !!! Nixed polyclonal !gC and !gN Nixed polyclonal !gC and !gN
-- Connective tissue diseases, chronic infections Connective tissue diseases, chronic infections
nticytoplasmic ntibodies nticytoplasmic ntibodies
- - Often more helpful in diagnosis than Often more helpful in diagnosis than
antibodies against nuclear antigens antibodies against nuclear antigens
- - Seen with multiple autoimmune diseases Seen with multiple autoimmune diseases
and several forms of vasculitis and several forms of vasculitis
nticytoplasmic antibodies nticytoplasmic antibodies
Disease Disease Cytoplasmic Cytoplasmic
ntigen ntigen
Frequency Frequency
Polymyositis Polymyositis tRN synthetase tRN synthetase
(anti (anti]o ]o1, etc) 1, etc)
20 2030% 30%
SLE SLE Ribosomal P Ribosomal P SS10% 10%
Wegener's Wegener's
granulomatosis granulomatosis
Serine proteinase Serine proteinase33
(in neutrophils) (in neutrophils)
30% 30%
Nicroscopic Nicroscopic
polyarteritis polyarteritis
Nyeloperoxidase Nyeloperoxidase
(in neutrophils) (in neutrophils)
70% 70%
Primary biliary Primary biliary
cirrhosis cirrhosis
Nitochondria Nitochondria 80% 80%
Hobbs, K. in West, S. Rheumatology Secrets. 2002.
nti ntineutrophil cytoplasmic neutrophil cytoplasmic
ntibodies (NC) ntibodies (NC)
- - C CNC NC
-- Nost commonly seen in Wegener's Nost commonly seen in Wegener's
granulomatosis, microscopic polyarteritis, granulomatosis, microscopic polyarteritis,
rarely Churg rarely ChurgStrauss vasculitis Strauss vasculitis
NC NC
- - PPNC NC
-- seen in multiple diseases as well as vasculitis seen in multiple diseases as well as vasculitis
PPNC NC
- - NPO positive NPO positive
-- Nicroscopic Nicroscopic
polyarteritis polyarteritis
-- Pauci Pauciimmune CN immune CN
-- Churg ChurgStrauss Strauss
vasculitis vasculitis
-- Drug Druginduced induced
syndromes syndromes
- - NPO negative NPO negative
-- Ulcerative colitis Ulcerative colitis
-- utoimmune disease utoimmune disease
-- H!v H!v
-- Chronic infections or Chronic infections or
neoplasms (rare) neoplasms (rare)
NC NC
- - !f pt. tests positive to NC, evaluation of !f pt. tests positive to NC, evaluation of
specific antigen testing for NPO and PR3 specific antigen testing for NPO and PR3
should be undertaken should be undertaken
- - !f C !f CNC is not against PR3 or P NC is not against PR3 or PNC is NC is
not against NPO, must consider causes not against NPO, must consider causes
other than vasculitis other than vasculitis
Rheumatoid factor Rheumatoid factor
- - utoantibody directed against the Fc utoantibody directed against the Fc
(constant) region of an !gC molecule (constant) region of an !gC molecule
-- Nultiple isotypes, including !gN, !gC, !g, and Nultiple isotypes, including !gN, !gC, !g, and
!gE !gE
-- !gN RF is routinely measured using latex !gN RF is routinely measured using latex
agglutination titers, nephelometry, and EL!S agglutination titers, nephelometry, and EL!S
Rheumatoid factor Rheumatoid factor
- - very low levels normal, but higher very low levels normal, but higher
production secondary to chronic immune production secondary to chronic immune
stimulation stimulation
- - RF positive in ~80% of patients with R RF positive in ~80% of patients with R
- - Nultiple other causes of positive RF Nultiple other causes of positive RF
Conditions associated with a Conditions associated with a
positive rheumatoid factor positive rheumatoid factor
- - Rheumatologic diseases Rheumatologic diseases
-- R (80 R (808S%) 8S%)
-- Sjogren's (7S Sjogren's (7S3S%) 3S%)
-- NCTD (S0 NCTD (S060%) 60%)
-- Scleroderma (20 Scleroderma (2030%) 30%)
-- Sarcoidosis (1S%) Sarcoidosis (1S%)
-- Polymyositis (S Polymyositis (S10%) 10%)
- - Non Nonrheumatologic rheumatologic
conditions conditions
-- Chronic hepatitis Chronic hepatitis
-- Pulmonary disease Pulmonary disease
-- Neoplasms Neoplasms
-- ging ging
-- Cryoglobulinemia Cryoglobulinemia
(40 (40100%) 100%)
-- !nfections !nfections
- - !DS, Nono, TB, syphilis, !DS, Nono, TB, syphilis,
parasites, endocarditis parasites, endocarditis
dapted from Kathryn Hobbs, from Rheumatology Secrets, 2002, p.60.
Frequency of RF positivity in Frequency of RF positivity in
normal population normal population
- - CE CE
-- 20 2060 years 60 years
-- 60 6070 years 70 years
-- >70 years >70 years
- - Frequency of +RF Frequency of +RF
-- 224% 4%
-- S% S%
-- 10 102S% 2S%
dapted from Kathryn Hobbs in West, S. Rheumatology Secrets, 2002.
nti ntiCCP antibodies CCP antibodies
- - EL!S assay based on filaggrin from EL!S assay based on filaggrin from
human skin or synthetic citrullinated human skin or synthetic citrullinated
peptides peptides
- - Target amino acid in filaggrin is citrulline, Target amino acid in filaggrin is citrulline,
a post a posttranslationally modified arginine translationally modified arginine
residue residue
- - High specificity and moderate sensitivity High specificity and moderate sensitivity
for R for R
nti ntiCCP antibodies CCP antibodies
- - Sensitivity 68% for R Sensitivity 68% for R
- - Specificity 38% for R Specificity 38% for R
- - Can be seen in active TB, other CTD Can be seen in active TB, other CTD
- - Clinical implications Clinical implications
-- Predictive of more aggressive disease with Predictive of more aggressive disease with
more progressive joint damage more progressive joint damage
Early antibody production as Early antibody production as
indicator of future disease? indicator of future disease?
- - Longitudinal study of 73 R patients Longitudinal study of 73 R patients
-- ~S0% produced anti ~S0% produced antiCCP b and/or !gN CCP b and/or !gNRF RF
prior to onset of disease prior to onset of disease
-- Positive results occurred median of 4.S years Positive results occurred median of 4.S years
(range 0.1 (range 0.113.8) before symptom onset 13.8) before symptom onset
-- Elevated levels of either !gN Elevated levels of either !gNRF or anti RF or antiCCP CCP
may imply high risk for development of R may imply high risk for development of R
N. ]. Nielen, et al. rthritis Rheum S0:380, 2004.
Complement Complement
- - Cascade of proteins activated by many Cascade of proteins activated by many
agents, including immune or antigen agents, including immune or antigen
antibody complexes antibody complexes
- - Nay be decreased due to Nay be decreased due to
-- !ncreased consumption (proteolysis) !ncreased consumption (proteolysis)
- - !ncreased levels of circulating immune complexes !ncreased levels of circulating immune complexes
activate classical pathway activate classical pathway
-- Decreased production Decreased production
- - Hereditary deficiency or liver disease Hereditary deficiency or liver disease
Hereditary complement deficiencies Hereditary complement deficiencies
- - Nay see SLE Nay see SLElike disease with deficiencies like disease with deficiencies
in C1 in C1C4 C4
- - Terminal complement (CS Terminal complement (CS3) deficiencies 3) deficiencies
lead to recurrent infections lead to recurrent infections
- - Deficiency in C1 !NH leads to angioedema Deficiency in C1 !NH leads to angioedema
(hereditary or acquired) (hereditary or acquired)
Diseases associated with low Diseases associated with low
complement levels complement levels
- - Rheumatic diseases Rheumatic diseases
-- SLE, systemic vasculitis, cryoglobulinemia, SLE, systemic vasculitis, cryoglobulinemia,
R (rare) R (rare)
- - Clomerulonephritis Clomerulonephritis
-- Post streptococcal and membranoproliferative Post streptococcal and membranoproliferative
- - !nfectious diseases !nfectious diseases
-- Bacterial sepsis, SBE, Hepatitis B, other Bacterial sepsis, SBE, Hepatitis B, other
viremias, parasitemias viremias, parasitemias
Complement level assessment Complement level assessment
- - C3 and C4 generally decreased with C3 and C4 generally decreased with
increased disease activity in SLE increased disease activity in SLE
- - Decreased levels may predict impending Decreased levels may predict impending
disease flares disease flares
-- C4 lowers before C3 and remains lower longer C4 lowers before C3 and remains lower longer
- - CHS0 not useful as disease activity marker CHS0 not useful as disease activity marker
Serum uric acid levels Serum uric acid levels
- - ge ge and sex and sexdependent dependent
- - Concentration levels rise with puberty in Concentration levels rise with puberty in
males and menopause in females males and menopause in females
- - ge of onset ge of onset
-- Peak for males: 40 Peak for males: 40S0 years S0 years
-- Peak for females: >60 years Peak for females: >60 years
Serum uric acid levels Serum uric acid levels
- - Hyperuricemia Hyperuricemia
-- > 7.0 mg/dL in males > 7.0 mg/dL in males
-- >6.0 mg/dL in females >6.0 mg/dL in females
- - 24 hour urine collection 24 hour urine collection
-- Urate >800 mg/24 hrs suggests Urate >800 mg/24 hrs suggests
overproduction overproduction
-- Urate <800 mg/24 hrs suggests Urate <800 mg/24 hrs suggests
underexcretion underexcretion
Serum uric acid levels Serum uric acid levels
- - !mportant considerations !mportant considerations
-- Only 1S% of pts. with hyperuricemia develop Only 1S% of pts. with hyperuricemia develop
gout gout
-- !f uric acid level>10mg/dL, risk increases to !f uric acid level>10mg/dL, risk increases to
30 30S0% S0%
-- !n ~10% of patients with acute gout, serum !n ~10% of patients with acute gout, serum
uric acid levels are normal uric acid levels are normal
- - Need joint aspiration and polarized light Need joint aspiration and polarized light
microscopy to diagnose with certainty microscopy to diagnose with certainty
symptomatic hyperuricemia symptomatic hyperuricemia
- - Treatment indications Treatment indications
-- cute overproduction e.g., tumor lysis cute overproduction e.g., tumor lysis
syndrome syndrome
-- Severe hyperuricemia e.g., uric acid levels Severe hyperuricemia e.g., uric acid levels
>12mg/dL >12mg/dL
- - Risk of uric acid nephrolithiasis is ~S0% Risk of uric acid nephrolithiasis is ~S0%
HL HLB27 B27
- - Sensitivity Sensitivity
-- ~3S% for S ~3S% for S
-- ~80% for Reactive rthritis ~80% for Reactive rthritis
-- ~70% for Sp associated with psoriasis ~70% for Sp associated with psoriasis
-- ~S0% for Sp associated with !BD ~S0% for Sp associated with !BD
-- ~70 ~7084% for uSp 84% for uSp
Shmerling RH. Ceriatrics,S1:22, 1336.
HL HLB27 B27
- - Specificity Specificity
-- Low given prevalence is ~8% in Caucasian Low given prevalence is ~8% in Caucasian
population population
- - !n patients with inflammatory back pain, !n patients with inflammatory back pain,
HL HLB27 positivity yields B27 positivity yields
-- 20 20fold increased risk of Sp fold increased risk of Sp
-- 1S 1Sfold higher risk of radiological sacroiliitis fold higher risk of radiological sacroiliitis
Braun ], et al. rthritis Rheum,41:S8, 1338.
Synovial fluid analysis Synovial fluid analysis
- - Studies to perform Studies to perform
-- Cram stain and culture Cram stain and culture
-- Total leukocyte count with differential Total leukocyte count with differential
-- Polarized microscopy Polarized microscopy
Synovial fluid analysis Synovial fluid analysis
Fluid type Fluid type ppearance ppearance Total WBC Total WBC
Count/mm Count/mm
33
%PNNs %PNNs
Normal Normal Clear, Clear,
viscous viscous
00200 200 <10% <10%
Non Non
inflammatory inflammatory
Clear to sl. Clear to sl.
turbid turbid
200 2002000 2000 <20% <20%
!nflammatory !nflammatory Slightly Slightly
turbid turbid
2000 2000
S0,000 S0,000
20 2070% 70%
Pyarthrosis Pyarthrosis Turbid Turbid >S0,000 >S0,000 >70% >70%
dapted from Spencer, RT in West, S. Rheumatology Secrets, 2002
Synovial fluid analysis Synovial fluid analysis
- - Noninflammatory joint effusions Noninflammatory joint effusions
-- O, joint trauma, mechanical derangement, vN O, joint trauma, mechanical derangement, vN
- - !nflammatory synovial fluid !nflammatory synovial fluid
-- Nultiple rheumatic disorders Nultiple rheumatic disorders
-- !nfectious arthritis !nfectious arthritis
- - Pyarthrosis Pyarthrosis
-- ]oint sepsis ]oint sepsis
-- Pseudosepsis in gout, reactive arthritis or R Pseudosepsis in gout, reactive arthritis or R
Polarized light microscopy Polarized light microscopy
Cout Cout Pseudogout Pseudogout
Crystal Crystal Nonosodium Nonosodium
urate (NSU) urate (NSU)
Calcium Calcium
pyrophosphate pyrophosphate
dihydrate (CPPD) dihydrate (CPPD)
Shape Shape Needle Needle Rhomboid or Rhomboid or
rectangular rectangular
Birefringence Birefringence Negative Negative Positive Positive
Crystal color Crystal color
parallel to axis parallel to axis
Yellow Yellow Blue Blue
dapted from Spencer, RT in West, S. Rheumatology Secrets, 2002
CPPD and NSU crystals CPPD and NSU crystals
Conclusions Conclusions
- - !mmunologic laboratory tests facilitate diagnosis !mmunologic laboratory tests facilitate diagnosis
and provide information regarding specific and provide information regarding specific
disease manifestations, disease activity and disease manifestations, disease activity and
prognosis prognosis
- - Clinical utility of laboratory evaluation can be Clinical utility of laboratory evaluation can be
enhanced by the employment of evidence enhanced by the employment of evidencebased based
guidelines guidelines
- - thorough history and physical examination thorough history and physical examination
remain the best screening and diagnostic tools remain the best screening and diagnostic tools
References
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