William E Davis, MD, FACP

 Markers of inflammation ◦ ESR ◦ CRP  Rheumatoid factor and anti-CCP antibodies  Anti-nuclear antibodies

 Acute phase response ◦ Cytokine production ◦ Hepatic plasma proteins ↑ 25%  CRP  SAA  Complement  Ceruloplasmin  Haptoglobin  Fibrinogen ◦ Negative acute phase proteins  albumin, prealbumin, transferrin  Transcription factors ◦ Signal transducer and activator of transcription 3 (STAT3) ◦ Janus activated kinase (JAK) ◦ Nuclear factor κB

 Edmund Biernacki  Robert Sanno Fåhræus

 Electrostatic charges prevent rouleaux formation and sedimentation  Plasma proteins and fibrinogen ↑  Microcytosis, polycythemia ↓  Pregnancy, ESRD ↑  Normal M <15mm, F < 20 mm  Elderly M = age/2  Elderly F = age/2+10

 Simple  Inexpensive  Strong evidence base

 Binds C-polysaccharide of streptococcus  Normal <1mg/dL (<10mg/L)  Binds apoptotic cells, Fcγ receptors, activates complement  >1000 fold increase in acute phase ◦ Peak 2-3 days ◦ T ½ = 19h  Persistently elevated in RA, tuberculosis, malignancy  > 15 mg/dL in bacterial infection

 Advantages ◦ Modest cost ◦ Automated nephelometry ◦ Serum test ◦ Evidence data base solid  Limitations ◦ Obese, elderly, ethnicity

 75 y/o caucasian male presents with new onset temporal headache x 2 weeks.  PMH: HTN, on ACE inhibitor  Normal vital signs and physical examination  ESR/CRP?

 47 y/o female with 10 year hx rheumatoid arthritis, on MTX and tnf-inhibitor (etanercept), presents with hx acute shaking chill, cough with brick red sputum, fever, physical examination and CXR c/w RML pneumonia  ESR/CRP?

1. Evaluate the extent or severity of inflammation 2. Monitor disease activity over time and with treatment 3. Assess prognosis

 Sheep cell agglutination test  IgM antibodies that recognize Fc of IgG  Normal: <15 I.U./L  1% young healthy, up to 5% elderly  Present in RA, Sjogren’s syndrome, HCV- cryoglobulinemia  Prognostic ΥΥ Υ Υ Υ Υ Υ

 Anti-perinuclear factor (APF)  Anti-keratin antibodies (AKA)  Citrullinated filaggrin  Cyclic citrullinated peptide (CCP)

 Sensitivity 82.9%  Specificity 93-94%  Predicts development of RA in early arthritis  Associated with severe, destructive disease ◦ Radiographic progression ◦ Total joint prosthesis ◦ Disability  May precede development of RA by years ◦ 30-60% CCP+ up to 6 years before dx

 48 y/o male with symmetric polyarthralgia progressive x 3-4 years  Hx HTN  PE: No joint swelling or deformity  Lab: normal CBC, mild increase AST, ALT <2x normal  RF + 55 IU  CCP negative  ?

 48 y/o male with symmetric polyarthralgia progressive x 3-4 years  Hx HTN  PE: No joint swelling or deformity  Lab: normal CBC, mild increase AST, ALT <2x normal  RF + 55 IU  CCP negative  HCV – chronic HCV associated with RF and arthralgia

 32 y/o female with symmetric polyarthralgia for 6 weeks; sx controlled with NSAID  PMHx: negative except G2P2  PE: Slight joint swelling and tenderness MCP’s, wrists, ankles & MTP’s  Lab: normal CBC, CMP, slightly elevated ESR 30, CRP 2 mg/dL  RF + 55 IU  CCP >100 U/ml  ?

 1948 LE Cell  1957 FANA test Υ Υ Υ Υ Υ Υ Υ Υ FITC Υ Υ Υ Υ

 Chromatin associated antigens ◦ DNA (dsDNA, ssDNA) ◦ Histone ◦ Kinetochore (centromere)  Ribonucleoproteins (snRNP) ◦ Sm ◦ U1 RNP ◦ Anti-Ro/SSA and Anti-La/SSB  Ribosomal P protein  Nucleolar antigens ◦ Kenetochore ◦ Topoisomerase ◦ RNA polymerase  PM-Scl-75 and PM-Scl-100 components of exoribonuclease  Aminoacyl-tRNA sythetases (Jo-1)

 Fluorescent ANA test ◦ Technician reads pattern and titer  Expensive  Subjective (1:160 or 1:320?)  Substrate ◦ Rodent liver or kidney ◦ Human cultured cell lines, e.g. Hep-2  ELISA for specific antigen specificity ◦ +ANA → ELISA testing

TiterPositive? 1:40 1:80 1:160 1:320 1:640 1:1280 1:2560 >1:5120

 Coat beads or microtiter plates with multiple antigens  Incubate patient plasma; measure reactivity  Any reactivity - positive -SSA/Ro -dsDNA -Sm RNP- SSB/La- Histone-

 31 y/o female presents with pericarditis  She reports intermittent joint swelling and pain, photosensitive dermatitis  WBC 3500, platelets 110,000  ANA 95% sensitive  Anti-Sm specific  Anti-dsDNA specific and high levels predict renal disease

 65 y/o F presents with several weeks inflammatory arthritis of hands.  PMH: HTN, CHF, multiple med’s  PE: swollen MCP joints  Lab: normal except WBC 4000, Platelets 125,000  ANA: 1:320, homogenous ◦ Negative DNA, Sm, SSA/Ro, SSB/La  Rheumatologist Rx’s hydroxychloroquine  Internist discontinues hydralazine  Anti-histone antibody positive

 58 y/o female has symmetric joint swelling without deformity; she has dry eyes and dry mouth and swollen parotid glands  Lab normal except hypergammaglobulinemia  RF 150 IU  CCP negative  ANA 1:1280  Anti-Sm, Anti-DNA neg  Anti-SSA, anti-SSB positive

 32 y/o female complains of fatigue, dyspnea, joint pain, and Raynaud’s phenomenon x 6 months  PE normal except Raynaud’s  Lab normal except ANA + 1:1280, nucleolar  Anti-topoisomerase (Scl70): diffuse systemic sclerosis  Anti-centromere : CREST syndrome ◦ Pulmonary vascular hypertension  Raynaud’s with negative ANA: 7% risk of rheumatic disease  Raynaud’s with positive ANA: 19-30% risk of rheumatic disease

 62 yo male with joint pain, Raynaud’s, and symptoms of proximal muscle weakness  CPK 2000  +ANA  40-80% PM/DM patients have +ANA  Anti-Jo-1 associated with “anti-synthetase syndrome” and interstitial lung disease

 Myositis  Raynaud’s, arthritis, puffy fingers  Lupus or scleroderma overlap  “MCTD”  Anti-RNP, Anti-PM-Scl

 Negative ANA: lupus unlikely  Positive ANA not helpful (%+): ◦ Discoid lupus (5-25) ◦ Fibromyalgia (15-25) ◦ Rheumatoid arthritis (30-50) ◦ Relatives of patients (5-25) ◦ Multiple sclerosis (25) ◦ Thyroid disease (30-50) ◦ Silicone breast implants (15-25)

 Symptomatic patient with Positive ANA: look for specificity ◦ Lupus: DNA and Sm specific  Anti-DNA prognostic and an activity marker  Histone may indicate drug induced  SSA, SSB correlate with neonatal damage ◦ Sjogren’s syndrome: SSA, SSB ◦ Systemic sclerosis (SSc): 97% +ANA  Centromere: limited sclerosis and pulmonary hypertension (CREST)  Topoisomerase/Scl70: diffuse disease with poor prognosis ◦ Inflammatory myositis: 40-80% + ANA, most specifics negative  Anti-Jo-1 : poor prognosis and risk of pulmonary hypertension  RNP, PM-Scl : associated with overlap syndromes (SLE, SSc)  Raynaud’s: ANA useful for prognosis

 ESR/CRP ◦ Identify extent or severity of inflammatory disease ◦ Monitor disease activity (RA) ◦ Assess prognosis in early arthritis  RF/CCP ◦ Use anti-CCP test to improve the specificity for RA ◦ +RF and +CCP predict worse prognosis  ANA ◦ Very sensitive test for SLE but technically challenging ◦ ANA specificities should be guided by clinical signs of autoimmune disease ◦ Prevalence of ANA specificities may be very low