Laboratory examinations in autoimmune disorders SLE ANA Antids

Laboratory examinations in autoimmune disorders 三軍總醫院 內科部風濕免疫過敏科

與風濕病相關的自體抗體 SLE: ANA, Anti-ds. DNA, Anti-Sm …… Drug-induced lupus: Anti-histone Rheumatoid arthritis: RF, ACPA (Anti- CCP) Mixed connective tissue disease (MCTD): Anti- RNP Polymyositis: Anti-Jo-1

與風濕病相關的自體抗體 Scleroderma : Anti-Scl-70, Anti-centromere Wegener’s granulomatosis: c-ANCA Microscopic polyangiitis p-ANCA Sjogren’s syndrome: Anti-Ro (SSA), Anti-La (SSB) Antiphospholipid syndrome: Anti-cardiolipin, lupus anticoagulant, Anti-beta 2 -glycoprotein-I Ab

Frequency of antibodies in various autoimmune diseases ANA Anti-ds DNA Anti-Sm Anti-RNP Anti. SSARo Anti. SSB-La Antihistone Anticentromere Anti. Jo-1 Anti. Scl-70 SLE ＞ 95﹪ 5080﹪ 25 -40﹪ 26 -45﹪ 3040﹪ 0 -15﹪ 2560﹪ － － － Drug-induced lupus ＞ 95﹪ Rare － － － 90﹪ － － － Mixed connective tissue disease 99﹪ Rare 100﹪ Rare 0 -20﹪ － － Rheumatoid arthritis 20 -50﹪ Rare 10﹪ 5 -7﹪ － 20﹪ － － － Sjogren's syndrome 20 -50﹪ － Rare 2070﹪ 3360﹪ － － － － Scleroderma 30 -50﹪ Rare 22﹪ 0 -7﹪ Rare － (CREST) 89 -90﹪ － 70% Polymyositis 20 -30﹪ Rare 0 -9﹪ Rare － － 2550﹪ －

Antinuclear antibodies (ANAs) ANA是血中的抗體對抗細胞核內的抗原 的自體抗體。 對抗: nucleic acids (DNA, RNA) nucleoproteins found in the connective tissue diseases

Antinuclear antibodies (ANAs) Homogeneous (diffuse): 1. Anti-ds DNA, Histones, Nucleosomes, Ku -- SLE, drug-induced SLE

Antinuclear antibodies (ANAs) Speckled pattern: 1. Anti-RNP, Anti-Sm (ribonucleoprotein, a component of splicesome) -- MCTD, SLE 2. SSA (Ro)/ SSB (La) (transcription termination factor) -- Sjögren’s syndrome -- Subacute cutaneous lupus

Antinuclear antibodies (ANAs) Nucleolar patterns: 1. Homogenous nucleolar pattern- anti-PM/ Scl --Systemic sclerosis, Polymyositis or Dermatomyositis 2. Clumpy nucleolar pattern- antifibrillarin -- Systemic sclerosis 3. Fine punctate nucleolar pattern- Antibodies to RNA polymerase -- Systemic sclerosis

Antinuclear antibodies (ANAs) Peripheral (rim): Anti-ds-DNA: SLE

Antinuclear antibodies (ANAs) Centromere pattern: Anti-centromere antibodies -- CREST syndrome, Sjögren’s syndrome CREST syndrome: Calcinosis, Raynaud’s phenomenon , Esophageal dysmotility, Sclerodactyly, Telangiectasia

Antinuclear antibodies (ANAs) Cytoplasmic pattern: -- may be related to primary biliary cirrhosis (PBC)

Antineutrophil cytoplasmic antibodies (ANCA) c-ANCA: n cytoplasmic staining n 對抗proteinase 3 n Wegener's Granulomatosis (90%) n Microscopic polyarteritis

Antineutrophil cytoplasmic antibodies (ANCA) p-ANCA: n peri-nuclear stain n against myeloperoxidase and against elastase n seen in patient with GN, various forms of vasculitis and collagen vascular disease

Anti-ds DNA Antibody 單股DNA抗體較無疾病的特殊性，雙股DNA 抗體(anti-ds DNA)則是SLE的特殊抗體之 一。 50 -80 % of SLE patients In SLE, anti-ds DNA antibody strongly correlate with nephritis and disease activity

Anti-phospolipid antibodies Lupus anticoagulant, Anticardiolipin Ab, Anti- beta 2 -glycoprotein-I Ab, Antiphosphotidyl serine Ab (APTS) Thromboembolism events: CVA, AMI, Pulmonary embolism, DVT, Ischemic bowel Recurrent abortion, Infertility, Pre-eclampsia Hemolytic anemia, thrombocytopenia SLE CNS involvement, Mononeuropathy multiplex Raynaud’s phenomenon, Livedo reticularis

Anti-Ro & La Antibody 30 -40% of SLE patients possess anti-Ro activity 0 -15 % of SLE possess anti-La SS-B/La大部分存在於紅斑性狼瘡或 Sjogren’s syndrome之病人，一般若SS-B/La 陽性的病人，會同時有SS-A/Ro抗體，反之則 不然。

Anti-Ro & La Antibody Anti-Ro is associated with photosensitive rash, subacute cutaneous lupus and the neonatal lupus syndrome In SLE, anti-La correlates with late-onset SLE, secondary Sjogren's syndrome, the neonatal lupus syndrome

Anti-Ro & La Antibody Anti-Ro (SS-A) antibodies recognize a set of primarily cytoplasmic ribonucleoproteins consisting of the 60 -k. Da Ro 60 antigen and a single molecule of human Y 1, Y 3, Y 4, or Y 5 RNA The 47 -k. Da La (SS-B) antigen associates transiently with the precursors of several small RNAs synthesized by RNA polymerase III, including Ro 60 ribonucleoproteins, and protects them from exonucleases. La is a termination factor for RNA polymerase III

Anti-Sm antibody Specific antibodies in the diagnosis of SLE 10 to 25 % of SLE patients Anti-Sm and anti-RNP autoantibodies recognize a set of small nuclear ribonucleoproteins (sn. RNPs) containing highly structured, uridine-rich small RNAs (U 1, U 2, U 4, U 5, and U 6 RNAs) involved in the splicing of messenger RNA Sm及RNP抗原是m. RNA製造過程所需要的Splicesome成員， 由核內小RNA(Sn. RNA)及蛋白質組合而成。抗體作用的 對象是蛋白質而不是RNA。

Anti-RNP antibody 100 % in MCTD、high-titer 26 to 45 % of SLE lower titers in several other rheumatic diseases, including primary Raynaud’s phenomenon, rheumatoid arthritis, and scleroderma

Nucleic acid components of some autoantigens

Anti- histone antibody Histone好比線軸承，供DNA纏繞，依分子量大 小分別是H 1、H 2 A、H 2 B、H 3及H 4 In the 20 to 60 % of SLE patients, predominantly target the H 1 and H 2 B proteins appear low uniformly in drug-induced lupus frequency in other diseases

Autoantibodies in scleroderma Anti-centromere antibody: limited cutaneous disease Anti-Scl-70 antibody: diffuse skin disease and interstitial lung disease Anti-RNA polymerase III antibody: worse prognosis, extensive skin thickening and renal crisis

C 3 Decreased C 3 levels: associated with most active diseases with immune complex formation

C 3 Decreased C 3 levels: Active SLE Absence of C 3 b inactivator factor Acute post-streptococcal glomerulonephritis Membranoproliferative glomerulonephritis End-stage liver disease Increased levels: found in numerous inflammatory states.

C 4 Decreased C 4 levels: Acute SLE Early glomerulonephritis Cryoglobulinemia Inborn C 4 deficiency Hereditary angioneurotic edema Increased levels: found in numerous inflammatory states.

全身性紅斑狼瘡病患常出現各種自體抗體 Anti-ds. DNA – lupus nephritis (84. 4) Anti-Ro/SSA - congenital heart block Anti-Ribosomal P – psychosis (88. 9) (neuropsychiatric) Anti-Neuronal – seizure Anti-Sm – specificity (最具特異性) (87. 1; 85. 7; 84. 10) (Anti-ds. DNA? ) Anti-phospholipid Ab--spontaneous abortion, neuropsychiastric lesions (CNS involvement) (88. 9)

全身性紅斑狼瘡病患常出現各種自體抗體 Anti-phospholipid antibody--Libman-Sachs氏心內膜炎 (Libman-Sachs endocarditis) (88. 6) Anti-Ro/SSA- 亞急性皮膚性紅斑狼瘡症(subacute cutaneous lupus erythematosus) --甚少侵犯中樞神經及腎 臟，預後甚佳，常出現廣泛的皮膚病變及關節炎 (88. 7) Anti-histone Ab – drug-induced lupus (87. 2) (86. 3) (85. 3)

Rheumatoid Factor an autoantibody that recognize abnormally glycosylated Ig. G seropositive or seronegative diseases: ‘sero’ means rheumatoid factor RF主要是一種對抗Ig. G的Ig. M抗體，但也可 以是Ig. G、Ig. A、Ig. D或Ig. E。

Rheumatoid factor in rheumatoid arthritis 診斷RA的criteria中的一項 High titers of RF, particularly Ig. G RF, are a risk factor for the development of vasculitis elevated Ig. A RFs may correlate with bone erosions, vasculitis, and a more severe disease course

Anti-citrullinated protein antibodies (ACPA) or anti-cyclic citrullinated protein antibodies (anti. CCP) During inflammation, arginine residues in proteins can be enzymatically converted into citrulline ones (a process called citrullination), and, if their shapes are significantly altered, the proteins may be seen as antigens by the immune system The most specific marker for the diagnosis of rheumatoid arthritis

Anti-citrullinated protein antibodies (ACPA) or anti-cyclic citrullinated protein antibodies (anti. CCP)