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Review for the generalist: The antinuclear antibody test in children - When to use it and what to do with a positive

titer
Peter N Malleson1, Murray J Mackinnon2, Michaela Sailer-Hoeck3 and Charles H Spencer4* Pediatric Rheumatology 2010,

Abstract
The antinuclear antibody test (ANA) is a much overused test in pediatrics. The ANA does have a role in serologic testing but it should be a very limited one. It is often ordered as a screening test for rheumatic illnesses in a primary care setting. However, since it has low specificity and sensitivity for most rheumatic and musculoskeletal illnesses in children, it should not be ordered as a screening test for non-specific complaints such as musculoskeletal pain. It should only be used as a diagnostic test for children with probable Systemic Lupus Erythematosus (SLE) or Mixed Connective Tissue Disease, (MCTD) and other possible overlap-like illnesses. Such children should have developed definite signs and symptoms of a disease before the ANA is ordered. This review presents data supporting these conclusions and a review of the ANA literature in adults and children. By limiting ANA testing, primary care providers can avoid needless venipuncture pain, unnecessary referrals, extra medical expenses, and most importantly, significant parental anxieties. It is best not to do the ANA test in most children but if it ordered and is positive in a low titer (<1:640), the results can be ignored if the child is otherwise well and does not have other features of a systemic illness.

Background
Since the introduction of the indirect immunofluorescence (IF) test for antinuclear antibodies (ANA) by Friou in 1957 [1], ordering an ANA appears to have become a reflexive response to the question "could this patient have a rheumatic disease?" What is the evidence that ordering such tests is of any value, and what should be done with a positive test?

The ANA test in health and disease


In diagnosing children with rheumatic disease, there are no markers as of now that identify a risk factor for a disease. Risk factors might allow primary prevention (e.g., screening for high serum cholesterol) or secondary prevention (e.g., detecting an illness before there are signs and symptoms e.g. pap smears for cervical cancer). In rheumatology only tertiary prevention is possible as illness may be detected as early in the disease course as possible in an effort to try and prevent the disease worsening and causing significant complications. Ideally there should be a screening test for children with arthritis or other positive rheumatic physical findings with a high specificity (test normal when someone does not have the disease) and high sensitivity (test abnormal when someone has the illness). A screening test should allow early diagnosis compatible with primary or secondary prevention. For children with arthritis, only a few diagnostic tests are available (e.g., Lyme titer) and the ANA in particular has very limited usefulness as a diagnostic test. To put it another way, ideally a test should always be positive in those with a disease, and always negative in those without a disease. This situation rarely if ever occurs, but to be useful a test generally needs to have sensitivity and specificity of at least 90%. That is, at least 9 out of 10 individuals with the disease will have a positive test, a "true positive", and 9 out of 10 individuals without the disease will have a negative test. Unfortunately the ANA test, whether performed by IF or by an enzyme linked immunosorbent method (ELISA), fails to demonstrate these test characteristics [2]. The ELISA particularly has its problem with false positives. Part of the problem is that the test is being used indiscriminately as part of "a rheumatologic work-up" or "rheumatology panel". No test can sensibly be expected to be accurate in the diagnoses of diseases as different as juvenile idiopathic arthritis (JIA), rheumatoid arthritis, SLE, MCTD, scleroderma, or the vasculitis diseases. Yet, in practice, this is what often seems to be asked of the ANA test. However, even if the test is used more sensibly to address specific questions such as: "does this child with a rash and fever have lupus?" or "does this child with a swollen knee have juvenile idiopathic arthritis (JIA)?", or "is this child with JIA going to develop uveitis?" we would argue that the ANA test is simply not accurate enough to answer even these questions.

ANA in healthy populations


A number of studies have looked at the frequency of positive ANA tests in "healthy" individuals. A study by Arroyave et al. in 1988 [3] screened sera from 241 "normal" children, testing for only IgG ANA, using both mouse kidney and human epithelial cells (HEp-2 cells). The study found a maximum positivity rate of only 2.0% at the lowest dilutions. However, data from adult studies have found much higher rates. In an adult study from 15 international laboratories using HEp-2 cells as substrate [4], ANA positive tests occurred in 31.7% of a putatively normal population at a serum dilution of 1:40. Even at a dilution of 1:320, 3.3% of the sera were positive. Interestingly the ANA frequency did not differ significantly across the age range of 20-60 years. The rate of ANA positivity among blood donors in Holland was also quite high at 12.7%, with titers greater than 1:80 occurring in over 4% [5]. It is not clear why there is such a low frequency of ANA positivity in children, compared to the much higher frequency found in most adult studies (of which only two of many are referenced here). As ANA tests are usually performed on children or adults with musculoskeletal or rheumatologic symptoms or signs, the frequency of ANA among clinic populations is more pertinent to our discussion than the situation in the normal population

ANA in clinic populations-ANA titers


Chudwin et al. in 1983 [6] evaluated the clinical and laboratory findings in 138 children with a positive ANA test. The authors interpreted the fact that two-thirds of the patients had a specific connective tissue disease as being indicative that the ANA test is useful. Yet the fact that one third did not have a definitive inflammatory disease indicates that the ANA test has a very high false positivity rate. We evaluated the results of all the ANA tests performed at British Columbia's Children's Hospital over a 5 year span [7]. We found that the ANA test was positive at a titer of 1:20 or greater in 41% of all sera tested, and in 65% of all patients in whom a diagnosis could be obtained from the ordering physician. The frequency was the same for those children with or without a diagnosis of a rheumatic disease. At a screening serum dilution of 1:40 a positive test had a sensitivity of only 63% and a positive predictive value (the frequency that a positive test is indicative of disease) of only 33% for any rheumatic disease. For SLE, MCTD or overlap syndrome, the ANA had a very high sensitivity of 98%, but a very low positive predictive rate of only 10%. Positive and negative predictive values are affected by the prevalence of the disease being tested. Therefore one might expect somewhat better predictive values from a pediatric rheumatology clinic than from a wide population of ill children. We concluded from this study that although a negative ANA test made the diagnosis of SLE or MCTD extremely unlikely, a positive test at even moderately high titers of 1:160 has little or no diagnostic value [7].

ANA immunofluorescent staining


As our laboratory also provided information on the patterns of immunofluorescent staining, we have also been able to evaluate what further use this information might provide (previously unpublished data). Of 1369 individual patients sera tested, 445 were ANA positive in children with a known diagnosis. Of these children, 135 had a rheumatic disease (juvenile rheumatoid arthritis (JRA) (now known as JIA-the terms are used interchangeably here), SLE, MCTD, or juvenile dermatomyositis (JDM) but 310 had no convincing evidence of having a rheumatic disease. Homogeneous, mitotic staining patterns were seen much more commonly in children with a rheumatic disease than those without (p = 0.001). Interestingly, a nucleolar pattern of staining was seen more commonly in children without a rheumatic disease (p = 0.03). This lack of an association of the nucleolar pattern in children with scleroderma specifically, and rheumatic disease in general has been commented on previously [8,9]. In our lab, no combination of ANA titer, or staining pattern was specific for any particular rheumatic disease. The test combinations with the best positive predictive values for a rheumatic disease were: a) a titer 1:640 with mitotic positive staining or b) a titer 1:640 with a homogenous and mitotic staining pattern. These tests had positive predictive values of 77% and 72% respectively. Yet these results were only slightly higher than the positive predictive value of 69% obtained with a titer of 1:640 alone, ignorin g the pattern of staining. Although the addition of patterns somewhat increases the specificity and positive predictive value of the ANA test for a rheumatic disease, it does so at the expense of both the sensitivity and negative predictive value of the test using titers alone. The pattern of staining also does not appear to be helpful in distinguishing between rheumatic diseases. For example, although high titer homogenous, mitotic positive staining was the most common combination seen in children with SLE, it was actually found in only 27.3% of ANA positive lupus patients. This combination was also found in 12.5% of ANA positive JRA and 5.4% of ANA positive JDM patients. This lack of specificity of the ANA immunofluorescent pattern has been recognized previously, both for adults and children [8,10,11]. A study by Parker et al. [11] evaluated the usefulness of combining ANA titer and pattern. Although they felt that knowledge of both titer and pattern was helpful, they did not calculate specific test characteristics, and in fact no combination was

restricted to any single rheumatic disease. Our assessment of these data is that the addition of information about patterns of immunofluorescence does not appear to significantly improve the utility of the ANA test.

Practical Concerns about ANA Testing Referrals for positive ANA titers
As part of a study exploring what precipitated a referral to a pediatric rheumatologist, McGhee et al. [12] found that children referred, at least in part, because of a positive ANA test were no more likely to have a chronic inflammatory disease than children with a negative test. In another study from a pediatric rheumatology clinic, only 55% of all of the children with a positive ANA test had an inflammatory rheumatic disease. Positive antibodies to double-stranded DNA or to extractable nuclear antigens (Sm, RNP) indicating SLE or MCTD were strongly correlated with an ANA titer 1:640. The authors recommended therefore, that these more specific tests be performed only if the child had a positive ANA test at high titer [13]. McGhee and colleagues reviewed the ANA titer clinical utility in 2004 [14]. One hundred and ten children were evaluated who had been referred for a positive ANA. Of the 110, 10 subsequently were found to have SLE, 18 had JRA, 1 had MCTD, and 1 had Raynaud's phenomenon. Neither a positive ANA neither titer nor the degree of positivity of the ANA helped pick out the children with SLE from the children without a chronic inflammatory disease. Tellingly, it wasn't the elevated ANA titer that distinguished the children with JRA from those with other musculoskeletal problems, but the history (e.g., morning stiffness) and the physical exam (e.g., presence of rash, swollen joints). All these studies demonstrate that a positive ANA test is found frequently in a pediatric hospital population, and even in high titer has only a poor ability to determine whether a child has an inflammatory rheumatic disease.

Development of rheumatic diseases in ANA positive individuals


It could be argued that the finding of a positive ANA test indicates that the child has an occult disease that will become manifest later. Is there any evidence to support or refute this? There is some evidence that ANA may sometimes precede the development of SLE by several years. Using Finland's Social Security Institution's population registry, Aho et al. [15] were able to trace 16 serum samples from apparently healthy subjects who later developed SLE or MCTD. Ten of the 16 (62.5%) samples were positive for ANA. Eight of the 11 (72.7%) were positive when the interval from sampling to onset of first symptoms was 2 years and 2 of 5 cases (40%) were positive when the interval was > 3 years. Based on an incidence rate of lupus of 5/100,000/year, the authors calculated that lupus would develop in less than one percent of the ANA positive individuals. Cabral et al. [16] followed the course of 24 children who were considered clinically not to have an inflammatory disease despite being ANA positive and found that no patient developed an overt inflammatory disease during a follow-up period of 61 months (range 13 to 138 months). Some studies have evaluated the outcome in patients with fibromyalgia. Fibromyalgia is a musculoskeletal pain condition not thought to be an autoimmune disease. Interestingly, some fibromyalgia patients are also ANA positive, but there has been no evidence that the occurrence of a positive ANA influences patient outcome. Al-Allaf et al. [17] found the ANA positivity rate (titers not given, a positive result was simply defined as "plus") in their adult patients with fibromyalgia was 8.8%. This rate was almost identical to the 8.9% ANA positivity rate in their control patients with osteoarthritis. The 12 individuals who had fibromyalgia and were ANA positive were matched for age and sex with 12 ANA negative patients. Over a 2-4 year follow-up period one patient in the ANA positive group fulfilled criteria for SLE, and one in the ANA negative group fulfilled criteria for Sjgren's syndrome. The authors concluded that the ANA test (at least in low titer) was not a good predictor of future connective tissue disease. In a separate study of 59 pediatric patients with fibromyalgia, 17 (28.8%) were ANA positive (mean titer 1:160). Fifty patients were followed for a mean of 18.3 months and during that time no patient developed a connective tissue disease [18]. We would conclude from these findings that only rarely is the presence of ANA the harbinger of occult SLE or another connective tissue disease.

ANA and other diseases


It should also be remembered that ANA are associated not only with the classical autoimmune diseases, but also with infection [19], malignancy [20,21] and drugs (Table 1) [22]. To illustrate this point, a study of Jones et al in 2006 analyzed 71 children who presented to a rheumatologist and who eventually were diagnosed with acute lymphocytic leukemia. Of the 71 children, 47 were tested for the ANA titer performed upon referral. Of the 47 ALL children, 8 (17%) had an elevated ANA titer [21]. Not only is the ANA test often positive in non-rheumatic diseases, it is often negative in many rheumatic diseases (Table 2).

Table 1. Diseases or syndromes that are frequently associated with an positive ANA test Table 2. ANA positivity in rheumatic diseases in children Environmental toxins may also predispose to ANA production. Although hopefully not relevant in pediatrics, there is evidence of an increased frequency of ANA in individuals with silicone breast implants [23], and at least two studies have suggested that rural populations have a higher frequency of ANA positivity than urban populations, perhaps due to toxin exposure [24,25]. Therefore the finding of a positive ANA test should not blind the physician to the possibility of a non-autoimmune diagnosis. A situation where a positive ANA test may be of some value is in children diagnosed with idiopathic thrombocytopenic purpura (ITP). In a study of 87 children with ITP, it was found that 36% of those with a positive ANA (titer 1:40) developed further "autoimmu ne symptoms". Five children developed SLE, compared to none of those who were ANA negative (p < 0.001). [26]

ANA positivity as a risk factor for uveitis in children with JIA


There is little doubt that in children with JIA the ANA test is more frequently positive in those with uveitis than in children without uveitis. The American Academy of Pediatrics recommends performing the ANA test as part of the screen for uveitis [27]. However, although there is a statistically significant difference between children with and without uveitis, we would argue that this difference itself is of little clinical significance. In a recent study from Finland [28], for example, uveitis was found in 104 of 426 new cases of juvenile idiopathic arthritis. Antinuclear antibodies were found in 66% of those with uveitis compared to 37% of those without uveitis, a statistically significant difference. However if the presence or absence of a positive ANA test was used in determining the frequency of ophthalmologic examinations, it is possible that some of the 46/104 children with uveitis and negative ANA's might well have had a delayed diagnosis due to the partial reliance on the ANA positivity to determine the frequency of eye checkups. So there is risk for ANA negative children as well. This should not detract from the utility of a positive ANA in selecting out a population of children with arthritis who are at a higher risk for uveitis.

What should be done?


So what should be done with a positive ANA test? Our answer would be exemplified by the answer a local inhabitant gave when asked directions from place A to B by a foreign tourist: "I wouldn't be leaving from here!" In other words, it would be best if the ANA test had not been done in the first place! We would suggest that a positive ANA test can safely be ignored unless there are other suggestive clinical signs, and simple laboratory tests (such as a raised ESR or cytopenias) that point towards a diagnosis of lupus or similar connective tissue disease, particularly if the ANA titer is less than 1:640. Given the high false positive rate of ANA tests, a positive test cannot be used as confirmatory evidence that the child with a swollen joint has JIA, rather than some other serious condition such as septic arthritis, leukemia, or hemophilia. Similarly, symptoms such as fatigue and aches and pains in a child should not be ascribed to SLE simply because of a positive ANA test. It is much more likely that such a child has an idiopathic pain syndrome such as fibromyalgia or hypermobility. A negative ANA test is more useful than a positive one, as it does, for all practical purposes, exclude the diagnosis of SLE in a child. What is needed is a cost-effectiveness study to evaluate whether the ANA test should be replaced by testing initially for anti-dsDNA and anti-ENA (anti-Sm, RNP, SSA and SSB) antibodies. Until that study is done, we would recommend that non-rheumatologists only do an ANA test if there is a fairly high probability (perhaps a 10+% chance) that a child's symptoms could be due to SLE or MCTD. If the test is positive at a titer of > 1:160 then it would be appropriate to order antibodies to dsDNA and ENA, with lower titers being ignored as well as complement levels. We would strongly recommend that the ANA test is not ordered indiscriminately as part of "a rheumatologic work-up". This is not a new message. Other pediatric rheumatologists have pointed out in the literature that the ANA is a poor screening test and is being used inappropriately[7,9,12,14,16,29,30]. It is our hope that a continued demonstration of these facts will gradually decrease its inappropriate use. The cost of inappropriate referrals, extra venipuncture, unnecessary expense, and increased parental and child anxiety is a considerable problem that pediatric rheumatologists see every day.

Conclusion
The question why the ANA test is so frequently positive in populations without an autoimmune disease remains a fascinating one. It suggests that the breaking of immunological tolerance is really quite common, but that this tolerance breakdown only rarely leads to disease. It is possible that antinuclear antibodies have some useful function that is not yet fully understood.

However, the ANA test has such a high false-positivity rate that a positive test is of little, if any, clinical utility as a screening test and should not be ordered routinely to screen children with musculoskeletal complaints. Its use should be limited to the diagnosis of SLE, MCTD, and similar systemic illnesses. If the test is performed, low titer ANA results (< 1:640) in most cases should be ignored unless the child is systemically ill and shows signs of SLE or a similar systemic disease.

Abbreviations
ANA: antinuclear antibody titer; SLE or lupus: systemic lupus erythematosus; HEp-2 cells: human epithelial cells used as ANA substrate; ENA: extranuclear antigens; MCTD: mixed connective tissue disease; JRA: juvenile rheumatoid arthritis; [(JIA): also known as juvenile idiopathic arthritis]; JDM: juvenile dermatomyositis; dsDNA: double stranded DNA antibodies; Sm: Smith antigen (one of the extractable nuclear antigens); RNP: ribonuclear protein antigen; (another of the extractable nuclear antigens): SSA: Sjgren's syndrome A antigen; (Ro): (one more of the extractable nuclear antigens); SSB: Sjgren's syndrome B antigen; (La): (another of the extractable nuclear antigens); ITP: idiopathic thrombocytopenic purpura; (JRA): juvenile rheumatoid arthritis; (JIA): and juvenile idiopathic arthritis are the old and new classification terms for chronic arthritis diseases in children. JRA is used preferentially here as the data collection began before the term JIA was more universally accepted.

Competing interests
The authors declare that they have no competing interests.

Authors' contributions
PM conceived the project, acquired the data, and reviewed the results; MM did the statistical analyses. PM, MSH, and CHS were responsible for the interpretation of the data and literature as well as preparation of the manuscript. The final manuscript was approved by the authors.

Acknowledgements
We would like to acknowledge the help of Louis Wadsworth MBBS, FRCPC, Director, Hematopathology Program British Columbia's Children's Hospital who provided generous help with acquiring the ANA data presented here.

References
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Extractable nuclear antigens Extractable Nuclear Antigens are over 100 different soluble cytoplasmic and nuclear antigens. Autoantibodies to these antigens are associated with particular connective tissue disorders. The six main antigens used in immunological laboratories for detection are Ro, La, Sm, RNP, Scl-70 and Jo1,[1] which are screened for by Ouchterlony double immuno diffusion techniques and confirmed by immunoblotting. On anti-nuclear antibody tests, these antigens have a speckled pattern. Terminology ENAs originally referred to proteins found in a saline extract of cell nuclei[citation needed]. Its components have since been more clearly identified and in fact include many cytoplasmic molecules. The misnomer however has stuck. These proteins are intimately associated with various RNA molecules and are thus called ribonucleoproteins, but the nomenclature used for them is often a source of confusion, Sm, Ro and La were named after the first 2 letters of the surnames of the patients in whom they were first found. Two proteins associated with Sjogren's Syndrome were independently described as antigens A and B, but are now known to be identical to Ro and La respectively. i.e. SS-A = Ro and SS-B = La. ENA 4 ENA 4 is a grouping of antibodies often used to screen for mixed connective tissue disease (MCTD), Sjgren's syndrome and systemic lupus erythematosus and commonly is composed of four tests:[3] anti-Sm (for SLE) anti-RNP (for MCTD) anti-La (for Sjgren's) anti-Ro (for Sjgren's)

Systemic Lupus Erythematosus Description

Systemic lupus erythematosus (SLE) is a chronic multisystemic disease of autoimmune origin SLE characteristically affects skin and joints, although any system can be involved SLE commonly affects women aged 20-45 years but may affect all age groups and both sexes American College of Rheumatology criteria for diagnosis of SLE suggest that four or more of the following must be present for the diagnosis to be made: malar rash, discoid rash, photosensitivity, oral ulcers, arthritis, serositis, renal disorder, neurologic disorder, hematologic disorder, immunologic disorder, antinuclear antibody (ANA) Treatment options are vast and dictated by the severity of disease; options include the use of nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, hydroxychloroquine, and more aggressive medications, such as cyclophosphamide and mycophenolate mofetil Synonyms SLE Lupus Immediate action

Cardiac, pulmonary, hematologic, renal, and neurologic symptoms and/or sepsis may be life- and/or organ-threatening. They must therefore be evaluated immediately. Urgent action

Urgent outpatient referral is appropriate if the diagnosis of SLE is suspected based on positive tests. Key points SLE is a chronic autoimmune multisystem disease with a fluctuating course It most commonly affects the skin and joints, and is most common in women aged 20-45 years, but does occur in all adult age groups of both sexes and can involve any body system The diagnosis is made on clinical grounds and on the presence of antibodies to nuclear antigens and to double-stranded DNA The most common presentation is with a butterfly rash on the face, low-grade fever, and nondeforming arthritis In mild cases, symptoms can be controlled by rest, NSAIDs, and avoidance of sunlight

NSAIDs are useful for arthralgia and hydroxychloroquine for the rashes More severe cases with multisystem involvement need treatment with systemic corticosteroids and/or other immunosuppressive agents Background Cardinal features

Cardinal features are difficult to define, as patterns of presentation are individual to the patient. Systemic lupus erythematosus (SLE) is characterized by flares and remissions, and virtually any body system can be involved. There is a wide variation in severity of the disease.

Cardinal features are best summed up from the criteria produced by the American College of Rheumatology: Tan EM, Cohen AS, Fries JF, et al. The 1982 revised criteria for the classification of systemic lupus erythematosus. Arthritis Rheum 1982;25:1271-7. The criteria were updated in 1997: Hochberg MC. Updating the American College of Rheumatology revised criteria for the classification of systemic lupus erythematosus [letter]. Arthritis Rheum 1997;40:1725

These criteria were designed for standardizing the inclusion of patients in clinical trials; however, they are useful as general clinical guidelines in the initial assessment of patients with suspected SLE: Malar rash: fixed erythema, flat or raised, over the malar eminences, tending to spare the nasolabial folds Discoid rash: erythematous, raised patches with adherent keratotic scaling and follicular plugging; atrophic scarring may occur in older lesions Photosensitivity: skin rash as a result of unusual reaction to sunlight, by patient history or physician observation Oral ulcers: oral or nasopharyngeal ulceration, usually painless, observed by physician Arthritis: nonerosive arthritis involving two or more peripheral joints, characterized by tenderness, swelling, or effusion

Serositis: (a) pleuritis - convincing history of pleuritic pain or pleural rub heard by a physician or evidence of pleural effusion, or (b) pericarditis - documented by electrocardiogram or pericardial rub or evidence of pericardial effusion Renal disorders: (a) persistent proteinuria greater than 0.5g/day or greater than 3+ (dipstick) if quantitation not performed, or (b) cellular casts - may be red cell, hemoglobin, granular, tubular, or mixed Neurologic disorder: (a) seizures in the absence of offending drugs or known metabolic derangements, e.g. uremia, ketoacidosis, or electrolyte imbalance, or (b) psychosis in the absence of offending drugs or known metabolic derangements, e.g. uremia, ketoacidosis, or electrolyte imbalance, (c) symptoms of stroke, (d) migrainous type headaches, (e) peripheral neuropathy, (f) transverse myelitis, (g) depression, (h) cognitive dysfunction Hematologic disorder: (a) hemolytic anemia with reticulocytosis, or (b) leukopenia <4000/mm3 total on two or more occasions, or (c) lymphopenia <1500/mm3 on two or more occasions, or (d) thrombocytopenia <100,000/mm3 in the absence of offending drugs Immunologic disorder: (a) anti-DNA: antibody to native DNA in abnormal titer, or (b) anti-Smith: presence of antibody to Smith nuclear antigen, or (c) positive finding of antiphospholipid antibodies based on: (1) an abnormal serum level of IgG or IgM anti-cardiolipin antibodies, (2) a positive test result for lupus anticoagulant using a standard method, or (3) a false-positive serologic test for syphilis known to be positive for at least 6 months and confirmed by the absence of Treponema pallidum immobilization or fluorescent treponemal antibody absorption test Antinuclear antibody (ANA): an abnormal titer of ANA by immunofluorescence or an equivalent assay at any point in time and in the absence of drugs known to be associated with 'drug-induced lupus' syndrome. Presence of positive ANA is a cardinal feature but is not specific for SLE

In addition: Constitutional symptoms: fatigue, fever, malaise, and weight loss Other skin rashes: including calcified nodules, vasculitis, leg ulceration, and scalp ulcers with or without alopecia Sicca syndrome (dry eyes/mouth) and Raynaud's phenomenon are common Cardiac involvement: pericardial rub in pericarditis and heart murmurs if there is endocarditis or valvular thickening/dysfunction Hypertension: systemic and pulmonary

Other features: including lymphadenopathy, splenomegaly, venous and arterial thrombosis Causes Common causes

The cause is unknown. Research involves: The role of viruses Hormonal factors (the female predominance and peak incidence in women of childbearing age is circumstantial evidence for hormonal factors in the pathogenesis of SLE) Genetic abnormalities (they may create a tendency for autoimmune responses, which are then triggered by additional factors, such as viruses or sunlight) Environmental factors (virus, sunlight) Immune complex formation - many of the clinical manifestations are due to the effects of circulating immune complexes on various tissues or to the direct effects of antibodies to cell-surface components Abnormal apoptosis Serious causes

SLE may be potentially life-threatening. Death most frequently occurs from nephritis or infection. Contributory or predisposing factors

Research suggests that many factors contribute to the immune dysfunction shown in lupus. These factors include: Genetic factors: evidence for genetic predisposition is shown by a concordance rate in monozygotic twins of around 30-50% Hormonal factors: evidence for hormonal influence can be deduced from the recognized fluctuations with flares in the postovulatory phase of the menstrual cycle. Pregnancy often exacerbates the disease (especially in those with nephritis or hypertension) Environmental factors (e.g. ultraviolet light and sunlight): evidence for photosensitivity comes from the fact that sunlight can precipitate SLE flares, particularly skin disease

Infectious agents are thought to possibly induce autoimmune responses by molecular mimicry or other as yet unknown mechanisms Drug-induced lupus syndrome: a syndrome with an SLE-like picture may be produced by several drugs, including procainamide, hydralazine, isoniazid, chlorpromazine, methyldopa, and TNF blocking agents. Most patients improve on withdrawal of the offending drug Epidemiology Incidence and prevalence

The incidence and prevalence of SLE varies across the world by race and ethnicity as well as geography. Incidence Varies from 1.8-7.6/100,000 per year in the US In northern Europe it has been reported to be 4/100,000 Prevalence Worldwide ranges from 2.9-400/100,000 Variable reporting results in a range from 14.6-50.8/100,000, with an average of 20/100,000 in the US Demographics Age Childbearing years (20-45 years) see the highest frequency (80% of cases) Can occur in all age groups, although uncommon before 8 years of age Under age 15 years, the reported incidence is 0.5/100,000 in the US Gender

Reported female:male ratios vary from 3:1 to 9:1 in adults, and are as low as 2:1 in prepubertal children. Race More common in African-Americans than Caucasians: US prevalence rates of up to 250/100,000 have been measured in Native Americans, Hispanics, Asians, and African-American patients

Certain communities have a higher prevalence rate - the Western Cape of South Africa has a high rate amongst those of mixed ancestry, but it is rare amongst the rural African population of South Africa Genetics No proven genetic transmission: genetic makeup may predispose to SLE Definite family relationships have been noted and some genetic profiles described The 1982 American College of Rheumatology (ACR) criteria summarized features necessary to diagnose SLE.[88, 5] These criteria were last updated in 1997.[5, 6] The presence of 4 of the 11 criteria yields a sensitivity of 85% and a specificity of 95% for SLE (see Table 1). Keep in mind that individual features are variably sensitive and specific. Patients with SLE may present with any combination of clinical features and serologic evidence of lupus.

The Systemic Lupus International Collaborating Clinics (SLICC) group revised and validated the ACR SLE classification criteria in 2012.[7] According to the revision, a patient is classified as having SLE if the patient has biopsy-proven lupus nephritis with ANA or anti-dsDNA antibodies or if the patient satisfies 4 of the diagnostic criteria (see below), including at least 1 clinical and 1 immunologic criterion.[7]

Also in 2012, the ACR published Guidelines for the Screening, Diagnosis, Treatment and Monitoring of Lupus Nephritis in Adults, as well as an evidence report for lupus nephritis.[91] ACR mnemonic of SLE diagnostic criteria

The following are the ACR diagnostic criteria in SLE, presented in the "SOAP BRAIN MD" mnemonic:

Serositis - Pleurisy, pericarditis on examination or diagnostic electrocardiogram (ECG) or imaging

Oral ulcers - Oral or nasopharyngeal, usually painless; palate is most specific

Arthritis - Nonerosive, 2 or more peripheral joints with tenderness or swelling

Photosensitivity - Unusual skin reaction to light exposure

Blood disorders - Leukopenia (< 4 103 cells/L on >1 occasion), lymphopenia (< 1500 cells/L on >1 occasion), thrombocytopenia (< 100 103 cells/L in the absence of offending medications), hemolytic anemia

Renal involvement Based on presence of proteinuria (>0.5 g/day or 3+ positive on dipstick testing) or cellular casts (including red blood cells [RBCs], hemoglobin, granular, tubular, or mixed)[91] or based on the opinion of a rheumatologist or nephrologist[91]

Antinuclear antibodies (ANAs) - Higher titers generally more specific (>1:160); must be in the absence of medications associated with drug-induced lupus

Immunologic phenomena - dsDNA; anti-Smith (Sm) antibodies; antiphospholipid antibodies (anticardiolipin immunoglobulin G [IgG] or immunoglobulin M [IgM] or lupus anticoagulant); biologic false-positive serologic test results for syphilis, lupus erythematosus (LE) cells (omitted in 1997 revised criteria)

Neurologic disorder - Seizures or psychosis in the absence of other causes

Malar rash - Fixed erythema over the cheeks and nasal bridge, flat or raised

Discoid rash - Erythematous raised-rimmed lesions with keratotic scaling and follicular plugging, often scarring

In patients with high clinical suspicion and/or high ANA titers, additional testing is indicated. This commonly includes evaluation of antibodies to dsDNA, complement, and ANA subtypes such as Sm, SSA, SSB, and ribonucleoprotein (RNP) (often called the ENA panel), as well as screening anticardiolipin antibodies, lupus anticoagulant, and +/- beta-2 glycoprotein antibodies. Diagnostic Studies

Standard laboratory studies that are diagnostically useful when systemic lupus erythematosus (SLE) is suspected should include the following:

Complete blood count (CBC) with differential

Serum creatinine

Urinalysis with microscopy

The CBC count may help screen for leukopenia, lymphopenia, anemia, and thrombocytopenia. Urinalysis and creatinine studies may be useful to screen for kidney disease.

Other laboratory tests that may be used in the diagnosis of SLE are as follows:

Erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP)

Complement levels

Liver function tests

Creatine kinase assay

Spot protein/spot creatinine ratio

Levels of inflammatory markers, including the ESR and CRP, may be elevated in any inflammatory condition, including SLE. However, the level of ESR elevation may show a discrepancy relative to a

normal CRP level in SLE flares; if both markers are markedly elevated, suspect the presence of an infectious process. CRP levels change more acutely, and the ESR lags behind disease changes.

Measurement of complement may be useful, because C3 and C4 levels are often depressed in patients with active SLE as a result of consumption by immune complexinduced inflammation. In addition, some patients have congenital complement deficiency that predisposes them to SLE.

Liver test results may be mildly elevated in acute SLE or in response to therapies such as azathioprine or nonsteroidal anti-inflammatory drugs (NSAIDS). Creatine kinase levels may be elevated in myositis or overlap syndromes.

The spot protein/spot creatinine ratio may be used to quantify proteinuria. The 2012 ACR guidelines for lupus nephritis indicate that a spot protein/spot creatinine ratio greater than 0.5 g/day can substitute for the 24-hour protein measurement and that an active urinary sediment (defined as >5 red blood cells [RBCs] per high-power field [hpf]; >5 white blood cells [WBCs]/hpf in the absence of infection; or cellular casts limited to RBC or WBC casts) can substitute for cellular casts.[91] Autoantibody tests

Table 3, below, summarizes the autoantibody tests that are used in the diagnosis of SLE.[92]

Table 3. Autoantibody Tests for SLE (Open Table in a new window) Test ANA Anti-dsDNA Anti-Sm Anti-SSA (Ro) or Anti-SSB (La) Anti-ribosomal P Description Screening test; sensitivity 95%; not diagnostic without clinical features High specificity; sensitivity only 70%; level is variable based on disease activity Most specific antibody for SLE; only 30-40% sensitivity Present in 15% of patients with SLE and other connective-tissue diseases such as Sjgren syndrome; associated with neonatal lupus Uncommon antibodies that may correlate with risk for CNS disease, including increased hazards of psychosis in a large inception cohort, although the exact role in clinical diagnosis is debated[93] Included with anti-Sm, SSA, and SSB in the ENA profile; may indicate mixed connective-tissue disease with overlap SLE, scleroderma, and myositis IgG/IgM variants measured with ELISA are among the antiphospholipid antibodies used to screen for antiphospholipid antibody syndrome and pertinent in SLE diagnosis

Anti-RNP Anticardiolipin

Lupus anticoagulant

Multiple tests (eg, direct Russell viper venom test) to screen for inhibitors in the clotting cascade in antiphospholipid antibody syndrome Direct Coombs test Coombs testpositive anemia to denote antibodies on RBCs Anti-histone Drug-induced lupus ANA antibodies are often of this type (eg, with procainamide or hydralazine; p-ANCApositive in minocycline-induced drug-induced lupus) ANA = antinuclear antibody; CNS = central nervous system; ds-DNA = double-stranded DNA; ELISA = enzyme-linked immunoassay; ENA = extractable nuclear antigen; Ig = immunoglobulin; p-ANCA = perinuclear antineutrophil cytoplasmic antibody; RBCs = red blood cells; RNP = ribonucleic protein; SLE = systemic lupus erythematosus; Sm = Smith; SSA = Sjgren syndrome A; SSB = Sjgren syndrome B.

Symptoms & Signs Symptoms vary from person to person, and may come and go. The condition may affect one organ or body system first. Others may become involved later. Almost all people with SLE have joint pain and swelling. Some develop arthritis. Frequently affected joints are the fingers, hands, wrists, and knees. Other common symptoms include: Chest pain when taking a deep breath Fatigue Fever with no other cause General discomfort, uneasiness, or ill feeling (malaise) Hair loss Mouth sores Sensitivity to sunlight Skin rash -- a "butterfly" rash over the cheeks and bridge of the nose affects about half of people with SLE. The rash gets worse in sunlight. The rash may also be widespread. Swollen lymph nodes

Other symptoms depend on what part of the body is affected: Brain and nervous system: Headaches Mild cognitive impairment Numbness, tingling, or pain in the arms or legs Personality change Psychosis Risk of stroke Seizures Vision problems

Digestive tract: abdominal pain, nausea, and vomiting Heart: abnormal heart rhythms (arrhythmias) Kidney: blood in the urine Lung: coughing up blood and difficulty breathing Skin: patchy skin color, fingers that change color when cold (Raynaud's phenomenon)

Diagnosis & Tests The diagnosis of SLE is based upon the presence of at least four out of eleven typical characteristics of the disease. The doctor will listen to your chest with a stethoscope. A sound called a heart friction rub or pleural friction rub may be heard. A neurological exam will also be performed. Tests used to diagnose SLE may include: Antibody tests, including: Antinuclear antibody (ANA) panel Anti-double strand (ds) DNA Anti-phospholipid antibodies Anti-smith antibodies CBC to show low white blood cells, hemoglobin, or platelets Chest x-ray showing pleuritis or pericarditis Kidney biopsy Urinalysis to show blood, casts, or protein in the urine

This disease may also alter the results of the following tests: Anti-SSA or -SSB antibodies Anti-thyroglobulin antibody Anti-thyroid microsomal antibody Complement components (C3 and C4) Coombs' test - direct Cryoglobulins ESR Rheumatoid factor RPR - a test for syphilis Serum globulin electrophoresis Serum protein electrophoresis