The ANA Test: All You Need To Know

04/24/2014
The ANA Test:
All You Need to Know
Department of Family and Community Medicine
Family Medicine Update
April 25, 2014
Celso R. Velázquez MD
Division of Rheumatology
University of Missouri
velazquezc@health.missouri.edu
Antinuclear antibodies (ANA)
• Diverse antibodies directed against nuclear components and
are the hallmark of autoimmune diseases.
• May be detected by
– ELISA (“180 units”)
– Immunoflourescence (“1:1280”)
– Immunoflourescence is better.
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ANA by ELISA
ANA by immunofluorescence (IF)
• Called “FANA” at Mizzou.
• Result is a titer (≥ 1:160 is significant) and a
pattern.
• More accurate than the ELISA
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Antinuclear antibodies
• Positive in 98% of patients with lupus
• Titers start at 1:40 and go up to 1:5160.
Titers ≥ 1:160 are considered positive.
• In general, higher titers are more specific but
the ANA titer does not correlate with the
severity of the disease.
ANA in healthy persons
• Titers ≥ 1:160 may be found in 5% of the
population, and titers ≥ 1:320 may be seen in
3% of the population
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ANA patterns on IF
• Centromere pattern: limited scleroderma (CREST)
• Nucleolar pattern: usually correlates with diffuse
scleroderma.
• Speckled pattern: usually correlates with Sjögren
syndrome.
• These have been replaced by the ANA panel.
The ANA panel:
the auto‐antibodies are more specific
but less sensitive.
• Anti‐DNA antibodies: quite specific for lupus
and are a useful marker of disease activity.
• Many other specific antibodies:
– Anti‐Sm: associated with lupus
– Anti‐SSA (Ro) and ‐SSB (La): associated with
Sjögren syndrome
– Anti‐RNP: associated with mixed connective tissue
disease
– Anti‐Scl‐70: associated with scleroderma
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The ANA panel:
not a good screening test.
Conditions associated with ANA
• Rheumatic diseases
– Systemic lupus erythematosus (SLE): 98%
– Discoid lupus: 15%
– Scleroderma: 85%
– Polymyositis and dermatomyositis: 61%
– Sjögren syndrome: 48%
– Rheumatoid arthritis: 41%
– Juvenile rheumatoid arthritis: 71%
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Conditions associated with ANA (2)
• Other autoimmune diseases
– Autoimmune thyroid disease (Graves’ and
Hashimoto’s)
– Autoimmune hepatitis
– Primary biliary cirrhosis
– Multiple sclerosis
• Other conditions
– Drug‐induced lupus
– Drug‐induced ANA
– Chronic infections (hepatitis C, HIV)
– Lymphoproliferative disorders
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So, when should we order an ANA?
• To establish a diagnosis in patients with
features suggestive of a connective tissue
disease
• To exclude connective tissue diseases in
patients with few findings
• To monitor disease activity (anti‐DNA)
A young woman with polyarthritis
and a rash
• Patients with SLE often also have fever,
serositis, cytopenias.
• Also order: CBC, creatinine, UA
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SLE: revised criteria
A woman with Raynaud phenomenon
• Raynaud phenomenon (RP) is seen in up to 5%
of the population and may be primary or
secondary. A negative ANA test suggests primary
RP.
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A 63 year‐old woman with dry eyes
and dry mouth.
• The prevalence of Sjögren syndrome (SjSd) is up to
2% of the population.
• Up to 50% of patients with SjSd may have a negative
ANA. A rheumatoid factor may be positive in these
patients.
Other scenarios:
• A child with polyarthritis  juvenile
rheumatoid arthritis
• A man with fever, arthritis and pleurisy after
taking hydralazine  drug‐induced lupus
• A man with proximal muscle weakness (but
not much pain)  polymyositis
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The ANA test if not very useful in:
• The patient with widespread pain and no
other organ system involvement.
• The patient with polyarthritis that is
characteristic of rheumatoid arthritis.
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• The patient with joint pain that is
characteristic of osteoarthritis.
ANA testing in the outpatient setting
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ANA testing in the outpatient setting
What do you do if the ANA is negative?
• What kind of assay did you order?
• Consider disease that can look like SLE:
– Sjögren syndrome
– Antiphospholipid syndrome
– Vasculitis
• The ANA is occasionally negative in patients
with SLE in remission or with end‐stage renal
disease.
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04/24/2014
What do you do if the ANA is positive
(≥ 1:160) but a low titer?
(And your rheumatologist says it’s not lupus…)
• When we say the patient does not have lupus we
mean that the patient does not have lupus right
now.
• Up to 30% of patients referred to a rheumatology
clinic for evaluation of a positive ANA develop
lupus upon follow‐up. The risk, however, is low
and around 5% in 10 years for persons with ANA
≥ 1:320.
• Serial exams and CBC and UA are indicated in
some patients.
Development of Autoantibodies before the
Clinical Onset of Systemic Lupus Erythematosus
• 115/130 patients with SLE had autoantibodies a mean of 3.3
years before diagnosis of SLE.
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The ANA Test:
All You Need to Know
(hopefully)
Thank you.
Celso R. Velázquez MD
Division of Rheumatology
University of Missouri
velazquezc@health.missouri.edu
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04/24/2014

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