Anti-nuclear antibody (ANA) test is commonly used to screen for systemic rheumatic disease. Indirect immunofluorescence assay using HEp-2 cells as substrate, containing approximately 100-150 autoantigens, is still the gold standard for ANA testing (1). Although the test name refers to only anti-nuclear antibody, there are often cytoplasmic staining patterns overserved in this assay. Cytoplasmic patterns result from antibodies against cytoplasmic components, like Jo-1 or Ribosomal P, and have clinical association with various systemic autoimmune disease, like polymyositis, systemic lupus erythematosus or primary biliary cirrhosis.
There is no standardized recommendation regarding how to report cytoplasmic pattern on ANA IFA, and laboratories independently decides whether to indicate cytoplasmic pattern in their result. The International Consensus on ANA Patterns (ICAP) workshop discussed this topic in 2015 and proposed two approaches for reporting ANA cytoplasmic patterns (2). Either to regard cytoplasmic pattern as positive or negative, both approaches recommended to include a statement of cytoplasmic staining.
We encountered cases in our laboratory in which reporting cytoplasmic staining had significant clinical values, and our laboratory started to report cytoplasmic staining as an additional comment in the test result a few years ago. Here is one of these cases:
Case: 35 year old woman with a history of hypertension complained about increasing muscle pain, weakness, and swelling. She had difficulties to raise her arms and had multiple falls, and was admitted to hospital three time for rhabdomyolysis. Her initial laboratory assessment were, CK >11,196 U/L, lactic acid 2.5 mmol/L, ALT 152 U/L, AST 416 U/L, and ALKP 42 U/L. Her ANA IFA test didn’t shown any nuclear staining, but there is very strong cytoplasmic staining observed. The clinician was suspecting inflammatory myositis and ordered myositis autoantibody panel to follow up. This panel detects numerous antibodies that are either specific or associated with inflammatory mycosis.
Her myositis autoantibody test result was positive for antibodies against signal recognition particle (SRP). SRP is an abundant, cytosolic, universally conserved ribonucleoprotein that targets specific proteins to the endoplasmic reticulum in eukaryotes and the plasma membrane in prokaryotes. Antibodies against SRP have been found in 5-8% of adult idiopathic inflammatory myopathies and <1% juvenile myopathies. It is closely associated with necrotizing myositis. Clinically it presents with acute onset, rapidly progressive, severe weakness, with high CK levels and commonly has cardiac and lung involvement.
Clinically significant antibodies can be present in patients with connective tissue disease that may appear as strong cytoplasmic staining on screening ANA test. It would be helpful to add a comment in these cases to aid the clinician in pursuing further work-up with a strong clinical suspicious of connective tissue disease.
References:
1. Position Statement: Methodology of Testing for Antinuclear. Antibodies American College of Rheumatology. 2009.
2. Damoiseaux J, et al. International consensus on ANA patterns (ICAP): the bumpy road towards a consensus on reporting ANA results. Auto Immun Highlights. 2016 Dec;7(1):1. doi: 10.1007/s13317-016-0075-0. Epub 2016 Jan 30.
-Xin Yi, PhD, DABCC, FACB, is a board-certified clinical chemist, currently serving as the Co-director of Clinical Chemistry at Houston Methodist Hospital in Houston, TX and an Assistant Professor of Clinical Pathology and Laboratory Medicine at Weill Cornell Medical College.
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