Laboratory tests in Rheumatology

Содержание

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Introduction In rheumatic disease lab test contribute to diagnosis Laboratory investigation

Introduction

In rheumatic disease lab test contribute to diagnosis
Laboratory investigation should be

guided by clinical picture
Measurement of biomarkers can be useful to monitor treatment efficacy and safety
Stratification of patients to predict prognosis
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Utility of Lab Tests Aims of lab test: 1. Identification of

Utility of Lab Tests

Aims of lab test:
1. Identification of pathological process

in the body & evaluation of its severity
2. Support or negation of specific diagnosis
3. Follow up of disease & complications
4. Detection of adverse reactions of drug therapy
Interpretation of lab tests should be done only in relation to certain clinical context.
Without the clinical picture most lab tests are useless.
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Diagnostic vs. Evaluative Tests Need to determine which test is appropriate

Diagnostic vs. Evaluative Tests

Need to determine which test is appropriate
Diagnostic tests

accurately distinguish a group of patients with a specific disease from a non-disease group
Evaluative tests monitor disease activity over time
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Blood Panel - Hemoglobin Anemia of chronic disease – usually normocytic

Blood Panel - Hemoglobin

Anemia of chronic disease – usually normocytic and

normochromic, but sometimes hypochromic microcytic
Should be differentiated from iron deficiency
Macrocytic anemia – not common in rheumatology, except for methotrexate treatment
Hemolytic anemia – LDH, Bilirubin, haptoglobin
Due to Gastrointestinal bleeding (acute or chronic)
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Blood panel - WBC White blood cells – neutrophils, lymphocytes, eosinophils:

Blood panel - WBC

White blood cells – neutrophils, lymphocytes, eosinophils:
Neutrophils are

acute phase reactants
Neutropenia – in patients undergoing immunosupressive treatment
Neutropenia can be associated with splenomegaly
Lymphopenia – active phases of SLE
Eosinophilia – Churg-Strauss (EGPA)
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Platelets Thrombocytosis can accompany active phases of autoimmune diseases – RA

Platelets

Thrombocytosis can accompany active phases of autoimmune diseases – RA (APR)
Thrombocytopenia

–
can be related to the presence of antithrombocyte antibodies, as in SLE
Drug induced toxicity
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Examples What CBC abnormalities do you expext in this patient?

Examples

What CBC abnormalities do you expext in this patient?

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Biochemical testing- liver Synthetic activity (albumin, coagulation factors, Glucose, Bil) Liver

Biochemical testing- liver

Synthetic activity (albumin, coagulation factors, Glucose, Bil)
Liver

enzymes – hepatocellular, cholestatic
Should be ordered before and after initiation of treatment (NSAIDS, DMARDS, including MTX, biological)
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Kidney function tests Connective tissue diseases and systemic vasculitides are frequently

Kidney function tests

Connective tissue diseases and systemic vasculitides are frequently associated

with kidney involvement – vascular/glomerular/tubular-interstitial
Creatinine/ Creatinine Clearance provide sufficient information
Urinalysis – always part of investigation (hematuria, leukocyturia, proteins)
Monitor for adverse effects of treatment
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Uric acid Commonly included in the workup of patients with arthritis

Uric acid

Commonly included in the workup of patients with arthritis
Elevated in

90% of patients with Gout
Healthy population can also have increased levels of uric acid
Important to monitor urate lowering therapy – goal of <5-6 mg/dL
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Acute-phase reactants Are not specific for rheumatic disorders AP response occurs

Acute-phase reactants

Are not specific for rheumatic disorders
AP response occurs in

a variety of inflammatory conditions – infection, trauma, malignancy.
The most widely used APR
ESR – erythrocyte sedimentation rate
CRP
Ferritin
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Acute phase reactants Produced by hepatocytes upon stimulation by cytokines (IL-1,

Acute phase reactants

Produced by hepatocytes upon stimulation by cytokines (IL-1, IL

-6, TNF – tumor necrosis factor)
Examples – CRP, fibrinogen, ferritin, haptoglobin, ceruloplasmin, amyloid protein A, complement (C3, immunoglobilins
ESR and CRP are useful for monitoring the level of inflammation, however sometimes are not sensitive enough and sometimes are “slow” and should not guide the clinical decisions
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Example What lab abnormalities do you expect in this patient?

Example

What lab abnormalities do you expect in this patient?

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Example What lab abnormalities do you expect in this patient?

Example

What lab abnormalities do you expect in this patient?

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Serologic testing Testing for autoantibodies is frequently used in the diagnoses

Serologic testing

Testing for autoantibodies is frequently used in the diagnoses of

rheumatic conditions and sometimes for monitoring of disease activity.
An adjunct to diagnosis and management rather than precise clinical guide.
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Rheumatoid Factor Autoantibodies directed against Fc– chains of IgG molecules Laboratories

Rheumatoid Factor

Autoantibodies directed against Fc– chains of IgG molecules
Laboratories test only

for IgM RF
The main immunoglobilin classes of RF that can be easily detected are IgA and IgM RF
IgM RF is produced in many chronic inflammatory conditions – endocarditis, hepatitis B/C, tuberculosis, Idiopathic pulmonary fibrosis, mixed connective tissue disease, SLE, cryoglobulinemia
Can be present in 5% of normal elderly population
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Rheumatoid Factor Not specific for Rheumatoid Arthritis The main indication for

Rheumatoid Factor

Not specific for Rheumatoid Arthritis
The main indication for RF testing

– suspicion for RA and Sjogren syndrome
The specificity of RF increases with higher titers
Higher titers are associated with more aggressive and erosive disease
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Antibodies to citrullinated protein and peptide ACPA- antigens Citrullination of proteins

Antibodies to citrullinated protein and peptide ACPA- antigens

Citrullination of proteins (arginine

– citrullin) occurs as the result of synovial inflammation and inflammation induced apoptosis
RA patients react to such modified proteins by creating ACPAs
ACPAs are especially prevalent in RF patients but can be found in 25% of RF negative patients
ACPAs predict later development of erosive RA
Helpful in discriminating between RA and psoriasis with erosive arthritis
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Anti-nuclear Antibodies (ANA) Immunoglobulins directed against structures within the cell (

Anti-nuclear Antibodies (ANA)

Immunoglobulins directed against structures within the cell ( i.e.

DNA, ribonuclear proteins, histones, and centromere)
Screening tool
Titer/ pattern
Found in a variety of autoimmune diseases such as SLE, MCTD, JRA, scleroderma, Sjogren’s syndrome in high titres (>1:320)
Almost always present in SLE (95-98%)
High titer increases the likelihood that the presence of ANA is related to autoimmune disease
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ANA ANAs do not correlate with disease activity Consider using as

ANA

ANAs do not correlate with disease activity
Consider using as a screening

test in only symptomatic patients (arthritis, rash, serositis, proteinuria)
Must measure ANAs in patients with JIA (esp. oligoarticular) to assess risk of uveitis
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ANA Low titres ( Infections (EBV, CMV, Hepatitis B, bacterial endocarditis,

ANA

Low titres (<= 1:160) found in:
Infections (EBV, CMV, Hepatitis B,

bacterial endocarditis, HIV)
Drugs (hydralazine, INH, dilantin, tegretol, ETX, PCN, and sulfas)
Neoplasias (lymphoma)
It is sensitive but not specific
~ 10% of the population have a positive low titer ANA and can be asymptomatic
As one ages, ANA titers increase
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ANA detection and measurement IIF - the indirect immunofluorescence test is

ANA detection and measurement

IIF - the indirect immunofluorescence test is the

most widely used assay for the detection of ANA and remains the reference method of choice for the detection of these antibodies
Nuclear staining patterns include: homogeneous, speckled, centromere, and nucleolar
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ANA patterns In the homogeneous staining pattern, the entire nucleus is

ANA patterns

In the homogeneous staining pattern, the entire nucleus is diffusely

stained. EX: Antibodies to histone proteins, DNA, and DNA-histone complexes.
In the speckled staining pattern, fine or coarse speckles are seen throughout the nucleus. Ex: Antibodies against U1 RNP, Sm, and La antigens.
The centromere pattern - anti centromere
The nucleolar pattern refers to homogeneous or speckled staining of the nucleolus; Ex: fibrillarin, RNA polymerase I and III, Th, PM-Scl, and RNA helicase.
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homogenous nucleolar speckled cenromere

homogenous

nucleolar

speckled

cenromere

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ELISA method Solid phase assays - enzyme-linked immunoabsorbant assays (ELISA) A

ELISA method

Solid phase assays - enzyme-linked immunoabsorbant assays (ELISA)
A panel of

purified native or recombinant autoantigens is prepared and each antigen is immobilized on a solid surface
The panel of antigens used in solid phase assays may include all or some of the following: Ro, La, Sm, U1 RNP, Scl-70, PM-Scl, Jo-1, centromere, histone, ribosomal P, and DNA.
Diluted human serum is incubated with the immobilized antigen and, as with the indirect immunofluorescence assay, a secondary antibody is used to detect bound autoantibodies.
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Advantages and Disadvantages The major advantage of indirect immunofluorescence is the

Advantages and Disadvantages

The major advantage of indirect immunofluorescence is the large

number of autoantibodies that can be detected.
Some autoantigens may not be present in the HEp-2 cell substrate
The Ro60 antigen, (SLE, Sjogren’s)
Anti-ribosomal P antibodies (SLE)
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Advantages and Disadvantages The number of autoantigens that are included in

Advantages and Disadvantages

The number of autoantigens that are included in solid

phase (ELIZA) assays is limited compared with the number that are present in the HEp-2 cell substrate. As an example, most solid phase assays do not contain antigens found in the nucleolus; patients with autoantibodies directed against these structures will have a falsely negative solid phase ANA result
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Anti-dsDNA antibodies Antibodies that target DNA Produce homogenous pattern in ANA

Anti-dsDNA antibodies

Antibodies that target DNA
Produce homogenous pattern in ANA IIF
Positive

result for anti-dsDNA screening should be confirmed by additional assays
Anti-dsDNA antibody testing is very specific (95%), but less sensitive (70%) for SLE
Are associated with disease activity in lupus nephritis
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Anti-histone antibodies Found in 95% of patients with drug-induced lupus syndrome

Anti-histone antibodies

Found in 95% of patients with drug-induced lupus syndrome
Seen with:
Procainamide
Quinidine
Hydralazine
Phenytoin

or other anti-epileptics
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Anti-Sm and anti-RNP antibodies “extractable” (ENA) Produce coarse speckled pattern in

Anti-Sm and anti-RNP antibodies “extractable” (ENA)

Produce coarse speckled pattern in ANA IIF
The

nucleoli are spared
Anti-Sm antibodies are almost exclusive for SLE patients, not sensitive (10-40%)
RNP antibodies are part of diagnosis of Mixed Connective Tissue Disease (a syndrome of arthritis, myositis, Raynauds’ and sclerodactly)
RNP antibodies are not specific for MCTD
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Anti-Sm and anti-RNP antibodies “extractable” (ENA) Anti-Sm antibodies generally remain positive,

Anti-Sm and anti-RNP antibodies “extractable” (ENA)

Anti-Sm antibodies generally remain positive, even when

a patient has entered remission. The titer of anti-dsDNA antibodies may fall into the normal range when a patient’s disease is quiescent
Anti-U1 RNP antibodies may be found in 3 to 69 percent of patients with SLE. High levels of anti-U1 RNP antibodies are always present in patients with mixed connective tissue disease (MCTD)
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Anti-Ro (SS-A) and anti-La (SS-B) antibodies (ENAs) Two sets of names

Anti-Ro (SS-A) and anti-La (SS-B) antibodies (ENAs)

Two sets of names assigned by

two different groups; first seen in Sjogren’s patients and then seen in SLE patients
Anti Ro/SS-A antibodies seen in:
5-15% of normals
50% of Sjogren’s patients
30% of SLE patients (many have negative ANA or subacute cutaneous lupus)
Correlates with active nephritis and cytopenias
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Anti-Ro (SS-A) and anti-La (SS-B) antibodies Produce fine speckled pattern in

Anti-Ro (SS-A) and anti-La (SS-B) antibodies

Produce fine speckled pattern in ANA

IIF with staining of the nucleoli as well
Are part of the classification criteria for Sjogren syndrome, but are also frequent in SLE patients
Are associated with cutaneous lupus and photosensitivity
Associated with neonatal lupus and congenital heart block
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Anticentomere and anti-SCL-70 Anticentromere antibodies (ACA) produce a typical pattern in

Anticentomere and anti-SCL-70

Anticentromere antibodies (ACA) produce a typical pattern in ANA

IIF by staining the centromere region of the chromosomes – this pattern is pathognomonic
The presence of anti-Scl-70 antibodies should be confirmed using ELIZA
These two antibodies are associated with distinct clinical pictures and are mutually exclusive
Anti-Scl-70 antibodies (also known as anti-topoisomerase I) are associated with increased risk of pulmonary fibrosis in both limited and diffuse cutaneous systemic sclerosis
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Antineutrophil cytoplasmic antibodies - ANCA Subgroup of neutrophil specific antibodies Commonly

Antineutrophil cytoplasmic antibodies - ANCA

Subgroup of neutrophil specific antibodies
Commonly directed to

myeloperoxidase (MPO) - and proteinase 3 (PR3)
P-ANCA – perinuclear staining (MPO)
C-ANCA – cytoplasmic staining (PR3)
Positive result on IIF should be confirmed using ELIZA
ANCA is useful in diagnosis of ANCA – associated vasculitides (GPA, EGPA, microscopic polyangiitis)
C-ANCA – GPA
P-ANCA – EGPA, microscopic polyangiitis
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ANCA c-ANCA is seen in 90% of GPA (Wegener’s granulomatosis) p-ANCA

ANCA

c-ANCA is seen in 90% of GPA (Wegener’s granulomatosis)
p-ANCA is associated

with microscopic polyangiitis, EGPA (Churg-Strauss), and Ulcerative Colitis
Consider vasculitis (ANCA) if patient has:
Fever of unknown origin
Palpable purpura, vasculitis urticaria, or dermal necrosis
Mononeuritis multiplex
Unexplained arthritis, myositis, or serositis
Unexplained pulmonary, CV or renal disease
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Complement The most frequent clinical parameters used for judging complement activation

Complement

The most frequent clinical parameters used for judging complement activation –

C3, C4
C3, C4 are APR
C3, C4 consumption is associated with immune complexes diseases
In SLE low levels reflect disease activity and in lupus nephritis normalization is associated with better outcomes
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Antiphospholipid antibodies (APLA) Anti-cardiolipin antibodies (ELIZA) IgG – better related to

Antiphospholipid antibodies (APLA)

Anti-cardiolipin antibodies (ELIZA)
IgG – better related to procoagulant activity

compared to IgM/IgA
β2glycoprotein-1 IgG and IgM
Lac - functional assay for the lupus anticoagulant (LA) phenomenon (prolonged aPTT/dRVVT) not corrected by control plasma but shortened by adding excess phospholipid
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Examples 24y woman presents with weakness, nausea, ptechia and echymozes

Examples

24y woman presents with weakness, nausea, ptechia and echymozes

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Laboratory analyses

Laboratory analyses

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Laboratory analyses

Laboratory analyses

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Examples 28y old woman presents with cough, fever, dyspnea, fatigue

Examples

28y old woman presents with cough, fever, dyspnea, fatigue

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Laboratory analyses

Laboratory analyses

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Laboratory analyses

Laboratory analyses

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Laboratory analyses

Laboratory analyses

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Example 42y old woman with SLE presents with fatigue, hair loss and new digital ulcer

Example

42y old woman with SLE presents with fatigue, hair loss and

new digital ulcer
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Examples

Examples

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Examples

Examples

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Examples 42y old man presents with weakness, loss of weight, puffy

Examples

42y old man presents with weakness, loss of weight, puffy painfull

hands, “hardening” of skin and hyperpigmentation
- Предыдущая
Знакомство детей с математическими знаками и монетами
Следующая -
Экспертиза промышленной безопасности

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