A practical guide for serologic evaluation of autoimmune connective tissue diseases,☆☆

https://doi.org/10.1016/S0190-9622(00)90121-XGet rights and content

Abstract

Serologic testing is important in the evaluation of patients with autoimmune connective tissue diseases (CTD). There are many techniques. Each of the tests has different sensitivity and specificity with varying diagnostic value. These serologic tests detect antibodies to numerous cellular components. The diagnostic significance and specificity of each antibody vary. Choosing the appropriate test and understanding its clinical utility is an important aspect in the diagnostic evaluation of patients with CTD. (J Am Acad Dermatol 2000;42:159-74.) Learning Objective: At the conclusion of this learning activity, participants should be familiar with the various serologic tests for CTD, should understand the associations of specific antibodies with individual CTD, and should identify the factors that influence the predictive value of these serologic tests.

Section snippets

BIOLOGY OF THE ANTIBODY SPECIFICITY

Patients with CTD have an autoimmune phenomenon that results in the production of antibodies against several self-antigens. These autoantibodies are directed against all cellular components, that is, nuclear, cytoplasmic, and cell membrane molecules. The binding of these antibodies to commercially available tissue extracts is the basis for serologic testing. Whether these antibodies play a role in the pathogenesis of the clinical manifestations of the disease is suspected but not confirmed with

TECHNIQUES FOR SEROLOGIC TESTING

The methods for the detection of the various antibodies have changed over the past few decades. Immunologic techniques that are commonly used during each time period have been utilized for the detection of these antibodies. For example, radioimmunoassay and immunoelectrophoresis were commonly used in the past.30, 31, 32, 33, 34, 35, 36 Radial immunodiffusion and immunofluorescence8, 10, 30, 32, 37, 38, 39, 40, 41, 42 remain of important value although both (especially the former) are being

ANTIBODIES TO DNA

Serum DNA antibodies may recognize nDNA (double-stranded) or denatured ssDNA by testing, depending on the type of epitope within the DNA molecule that they recognize. The diagnostic significance of each of the two antibodies is different. The two types of antibodies will be discussed separately.

RNP ANTIBODIES

Of all the types of cellular RNA, autoantibodies in patients with CTD are directed to the small ribonucleoproteins (sRNP). This type constitutes the smallest portion of cellular RNA (<1% of the total RNA). sRNP consists of several molecules that contain RNA and an associated protein, thus the term ribonucleoprotein .26, 92 The protein component has enzymatic activity and plays a role in the processing of the RNA molecule.92 Antibodies to sRNP are directed against epitopes within the protein

OTHER AUTOANTIBODIES

Several other autoantibodies have been reported in patients with CTD. The diagnostic value of most of these antibodies is limited; only two are discussed in this review. Scl-70 antibodies are directed against the enzyme topoisomerase-I.138, 139, 140 This is a 100-kd basic protein that affects the tertiary structure of DNA molecules. Scl-70 antibodies are characteristic of SSc and help differentiate patients with extensive cutaneous and systemic involvement from those with limited disease.131,

FLUORESCENT ANA TEST

The fluorescent ANA test is a very good screening test for most of the previously discussed antibodies.

DIAGNOSTIC VALUE OF THE FLUORESCENT ANA TEST

There are several parameters that indicate the value of a certain test. These include sensitivity, specificity, positive predictive value, negative predictive value, and marginal benefit. Sensitivity refers to the probability of a test to have a positive result in a patient with the disease (true positives ÷ [true positives + false negatives]).12 Specificity refers to the probability of a test to have a negative result in a person without disease (true negatives ÷ [true negatives + false

RECENT SCREENING ANA TESTS

In the past few years, attempts have been made to replace the fluorescent ANA test with ELISA screening tests. There have been many ELISAs that have been reported to be of value for screening ANA tests. Some of these ELISAs utilize extracts of tissue containing various nuclear components. Other ELISAs utilize molecules synthesized by recombinant technology. Some ELISAs utilize individual recombinant molecules such as Ro(SS-A), whereas others utilize combinations of various molecules to increase

SEROLOGIC PROFILES IN CTDS

Each CTD has a rather specific autoantibody profile (Fig 1). Some of these profiles are “simple” in that they include one characteristic antibody (eg, anticentromere antibodies in patients with CREST5, 28, 29, 170, 171 and anti-U1RNP antibodies in patients with MCTD15, 23, 24, 25, 127). On the other hand, patients with SLE have a larger array of autoantibodies. Some of these antibodies are highly character-istic for SLE (nDNA antibodies1, 4, 49, 51, 172 and Sm antibodies15, 16, 104, 107, 134),

ANTIPHOSPHOLIPID ANTIBODIES

Antiphospholipid antibodies (APAs) are directed against negatively charged phospholipids, present in cell membranes.58, 173, 174, 175, 176, 177

References (198)

  • MJ Fritzler et al.

    Antinuclear, anticytoplasmic, and anti-Sjogren’s syndrome antigen A (SS-A/Ro) antibodies in female blood donors

    Clin Immunol Immunopathol

    (1985)
  • W Emlen et al.

    A new ELISA for the detection of double-stranded DNA antibodies

    J Immunol Methods

    (1990)
  • JL Carey

    Enzyme immunoassays for antinuclear antibodies

    Clin Lab Med

    (1997)
  • JP Callen et al.

    Serologic and clinical features of patients with discoid lupus erythematosus: relationship of antibodies to single-stranded deoxyribonucleic acid and of other antinuclear antibody subsets to clinical manifestations

    J Am Acad Dermatol

    (1985)
  • D Buskila et al.

    Autoantibody profile in the sera of women with hyperprolactinemia

    J Autoimmun

    (1995)
  • M Monestier et al.

    Antibodies to histones in systemic lupus erythematosus and drug-induced lupus syndromes

    Rheum Dis Clin North Am

    (1992)
  • JP Portanova et al.

    Reactivity of anti-histone antibodies induced by procainamide and hydralazine

    Clin Immunol Immunopathol

    (1982)
  • RL Yung et al.

    Drug-induced lupus

    Rheum Dis Clin North Am

    (1994)
  • RW Burlingame

    The clinical utility of antihistone antibodies

    Clin Lab Med

    (1997)
  • A Aitkaci et al.

    Enzyme-linked immunosorbent assay for anti-histone antibodies and their presence in systemic lupus erythematosus sera

    J Immunol Methods

    (1981)
  • J Craft

    Antibodies to snRNPs in systemic lupus erythematosus

    Rheum Dis Clin North Am

    (1992)
  • EJ ter Borg et al.

    Clinical associations of antiribonucleoprotein antibodies in patients with systemic lupus erythematosus

    Semin Arthritis Rheum

    (1990)
  • TT Provost et al.

    Significance of the anti-Ro(SS-A) antibody in evaluation of patients with cutaneous manifestations of a connective tissue disease

    J Am Acad Dermatol

    (1996)
  • WD Dickey et al.

    Presence of anti-La(SS-B) is associated with binding to the 13-kD carboxyl terminus of 60-kD Ro(SS-A) in systemic lupus erythematosus

    J Invest Dermatol

    (1993)
  • Y Takeuchi et al.

    The comparative study of anti-double stranded DNA antibody levels measured by radioimmunoassay and enzyme-linked immunosorbent assay in systemic lupus erythematosus

    J Dermatol

    (1997)
  • H Krippner et al.

    Enzyme immunoassay for IgG and IgM antibodies against dsDNA and ssDNA

    Z Rheumatol

    (1983)
  • PE Spronk et al.

    Anti-DNA antibodies as early predictor for disease exacerbations in SLE: guideline for treatment?

    Clin Rev Allergy Immunol

    (1998)
  • TP Chorzelski et al.

    Anticentromere antibody: an immunological marker of a subset of systemic sclerosis

    Br J Dermatol

    (1985)
  • DL Tuffanelli et al.

    Cutaneous manifestations of systemic lupus erythematosus

    Arch Dermatol

    (1964)
  • AR Cabral et al.

    Autoantibodies in systemic lupus erythematosus

    Curr Opin Rheumatol

    (1998)
  • A Pahor et al.

    The clinical significance of antinuclear antibodies in connective tissue disease

    Wien Klin Wochenschr

    (1998)
  • EM Tan et al.

    Range of antinuclear antibodies in “healthy” individuals

    Arthritis Rheum

    (1997)
  • TT Provost et al.

    Antinuclear antibodies in systemic lupus erythematosus

  • MM Ward

    Laboratory testing for systemic rheumatic diseases

    Postgrad Med

    (1998)
  • RD Sontheimer et al.

    Antinuclear antibodies: clinical correlations and biologic significance

    Adv Dermatol

    (1991)
  • M Hamburger et al.

    The incidence and clinical significance of antibodies to extractable nuclear antigens

    Am J Med Sci

    (1977)
  • M Field et al.

    Specificity of anti-Sm antibodies by ELISA for systemic lupus erythematosus: increased sensitivity of detection using purified peptide antigens

    Ann Rheum Dis

    (1988)
  • MJ Fritzler

    Antinuclear antibodies in the investigation of rheumatic diseases

    Bull Rheum Dis

    (1985)
  • MJ Fritzler

    Clinical relevance of autoantibodies in systemic rheumatic diseases

    Mol Biol Rep

    (1996)
  • M Hietarinta et al.

    Clinical significance of antinuclear antibodies in systemic rheumatic diseases

    Ann Med

    (1996)
  • D Thompson et al.

    The clinical significance of autoantibody profiles in patients with systemic lupus erythematosus

    Lupus

    (1993)
  • Y Tomer et al.

    Pathogenic significance and diagnostic value of lupus autoantibodies

    Int Arch Allergy Immunol

    (1993)
  • B Combe et al.

    Clinical significance of anti-RNP and anti-Sm autoantibodies as determined by immunoblotting and immunoprecipitation in sera from patients with connective tissue diseases

    Clin Exp Immunol

    (1989)
  • JN Gilliam et al.

    Mixed connective tissue disease syndrome: cutaneous manifestations of patients with epidermal nuclear staining and high titer serum antibody to ribonuclease-sensitive extractable nuclear antigen

    Arch Dermatol

    (1977)
  • I Lundberg et al.

    Clinical course of patients with anti-RNP antibodies: a prospective study of 32 patients

    J Rheumatol

    (1991)
  • AA Juby et al.

    Specificity, sensitivity and diagnostic predictive value of selected laboratory generated autoantibody profiles in patients with connective tissue diseases

    J Rheumatol

    (1991)
  • DJ de Rooij et al.

    Marker antibodies in scleroderma and polymyositis: clinical associations

    Clin Rheumatol

    (1989)
  • DL Tuffanelli et al.

    Anticentromere and anticentriole antibodies in the scleroderma spectrum

    Arch Dermatol

    (1983)
  • DJ de Rooij et al.

    The use of immunoblotting to detect antibodies to nuclear and cytoplasmic antigens: clinical and serological associations in rheumatic disease

    Scand J Rheumatol

    (1988)
  • PH Schur et al.

    Immunological detection of nucleic acids and antibodies to nucleic acids and nuclear antigens by counterimmunoelectrophoresis

    Clin Exp Immunol

    (1974)
  • Cited by (41)

    • Alterations in Blood Components

      2018, Comprehensive Toxicology: Third Edition
    • The transcription, translation, transport-trail and autoimmunity: Guilt by association

      2015, Medical Hypotheses
      Citation Excerpt :

      The autoimmune connective tissue diseases (ACTD) are a group of diseases characterized by systemic autoimmunity and autoantibody production [1].

    • Structure of the Skin and Cutaneous Immunology

      2014, Middleton's Allergy: Principles and Practice: Eighth Edition
    • Antinuclear Antibody Testing

      2012, Hospital Medicine Clinics
      Citation Excerpt :

      The ANA test should not be used for general screening or indiscriminately. The ANA may be less useful in the elderly and in patients with chronic infections or malignancies.7,21 Tags: low predictive value ANA.

    • The lichenoid reaction pattern ('interface dermatitis')

      2009, Weedon's Skin Pathology: Third Edition
    • Cutaneous histopathology of lupus erythematosus

      2009, Diagnostic Histopathology
      Citation Excerpt :

      The significance of seropositivity for antibodies to the cellular antigens depends upon the total quantity of antibody present, as indicated by the titre and nature of the assay used, as well as by the specificity of the antibody. With respect to the former, most reference commercial laboratories employ enzyme-linked immunosorbent assay (ELISA) technology, which is more sensitive, but less specific, than the older immunodiffusion methodologies.95 The nature of the antigen specificity as it relates to specific diagnostic categories of connective tissue disease is represented in Table 4.

    View all citing articles on Scopus

    Reprint requests: Diya F. Mutasim, MD, Professor and Chairman, Department of Dermatology, University of Cincinnati, PO Box 670592, Cincinnati, OH 45267-0592. E-mail: [email protected].

    ☆☆

    0190-9622/2000/$12.00 + 0  16/2/103582

    View full text