1. RHEUMATOLOGY TESTING Maureen Sestito, D.O. PCOM Internal Medicine Residency

2. Rheumatology The medical specialty concerned with the study, diagnosis and treatment of disorders of the articular system.

3. Immunolgy The science concerned with the various phenomena of immunity, induced sensitivity, and allergy.

4. Medicine Diabetes, Heart Disease and Rheumatic Disorders.

5. RHEUMATOLOGY TESTING Overview of the general efficacy of diagnostic studies. Serologic Studies Synovial Fluid Radiologic Imaging

6. Rheumatologic Evaluation b All Rheumatologic and Immune related disorders have criteria for classification that include both clinical and laboratory findings.

7. Rheumatologic Evaluation b Testing is performed to define the extent of disease or to detect other organ systems that may be involved.

8. Rheumatologic Evaluation b The laboratory evaluation of patients with Rheumatic disease is often informative, but rarely definitive.

9. Rheumatologic Evaluation b All Rheumatologic and Immune mediated disorders fall into a spectrum of criteria that often overlap. b The lines between diagnosis are often blurred.

10. Serologic Testing ANA Rheumatoid Factor Acute Phase Reactants AutoantibodiesComplement

11. Anti Nuclear Antibodies 5% of healthy people have positive ANA titres. The incidence is greater in women. Highly sensitive but has a low specificity.

12. Anti Nuclear Antibodies Patterns PeripheralDiffuseSpeckledNucleolar

13. Anti Nuclear Antibodies Positivity SLE 95-99% Sjogrens 75% RA 15-35% Systemic Sclerosis 60-90% Drug Induced Lupus 100% MCTD 95-99%

14. Anti Nuclear Antibodies Monitoring or Prognosis b Raynauds b Juvenile Arthritis with Uveitis

15. Anti Nuclear Antibodies Intrinsic Part of the Diagnostic Criteria Drug Induced SLE Autoimmune Hepatitis MCTD

16. Anti Nuclear Antibodies Not Useful b Rheumatoid Arthritis b Multiple Sclerosis b ITP b Thyroid DiseaseDiscoid Lupus b Infectious Diseases b Malignancies b Silicone Breast Implants b Fibromyalgia b Relatives with autoimmune Diseases

17. Rheumatoid Factor b IgM Antibody to IgG b 1-2% of healthy people are positive b Positive RF increases with age b Positive in 75% of people with Rheumatoid Arthritis

18. Rheumatoid Factor Diseases with Positive RF b Subacute Bacterial Endocarditis b Leprosy b Tuberculosis b Syphilis b Lymes Disease b Rubella b CMV b Mononucleosis b Influenza b Sarcoidosis b Periodontal Disease b Mixed Cryoglobulinemia

19. ACUTE PHASE REACTANTS Parallel Chronic Inflammation Discriminate Inflammatory from Non-inflammatory

20. ACUTE PHASE REACTANTS ACUTE PHASE REACTANTS Elevated In: Infections Inflammatory Arthritis Autoimmune Disorders NeoplasiaPregnancy Advanced Age

21. ACUTE PHASE REACTANTS ACUTE PHASE REACTANTS COAGULATIONFibrinigenProthrombinTRANSPORTHaptoglobinTransferrinCeruloplasmCOMPLIMENTS C3 & c4 Protease Inhibitors AlbuminFibronectinCRP Amyloid A

22. ACUTE PHASE REACTANTS ACUTE PHASE REACTANTS b ERYTHROCYTE SEDIMENTATION RATE b Men: b Upper limit= age divided by 2 b Women: b Upper limit= (age + 10) divided by 2

23. ACUTE PHASE REACTANTS ACUTE PHASE REACTANTS ESR/CRPElevatedInflammationAnemia Renal Failure PregnancyDecreased Changes in Red Cell Morphology Decreased Fibrinogen CryglobulinemiaCHF

24. ACUTE PHASE REACTANTS ESR/CRP ACUTE PHASE REACTANTS ESR/CRP ESR Criteria for Diagnosis: Giant Cell Arteritis Polymyalgia Rheumatica Monitoring Disease Activity: RAPMRGCA Not Useful: SLESpondyloarthropathiesGout Septic Arthritis

25. AUTOANTIBODIES b There is a great deal of overlap among the diagnostic categories. b Sensitivities and specificities vary dramatically. b Assay methods and units are not always standardized.

26. COMPLEMENT 20 Biologically active proteins and inhibitors CH50 The best screening test Functional assay of the entire pathway

27. HYPOCOMPLEMENTEMIA With Immune Complex Formation SLE Idiopathic Membranoproliferative GlomerulonephritisCryoglobulinemiaVasculitis Post Strep GN Serum Sickness Without Immune Complex Formation Atheromatous Embolization HUS Septic Shock Liver Failure MalnutritionPancreatitisBurnsMalariaPorphoria

28. Conclusion