Terry Kotrla, MS, MT(ASCP)BB

Unit 3 AutoimmunityPart 2 Systemic Lupus

ErythematosusPart 3 Rheumatoid Arthritis

ExpectationStudents are expected to know:

Signs and symptoms, especially part of body affected

Age and sex if appropriateTests to diagnoseTreatment

Systemic Lupus ErythematosusChronic, systemic inflammatory disease

caused by immune complex formation.The word "systemic" means the disease can

affect many parts of the body. Pathophysiology associated with clinical

features secondary to immune complexes depositing in tissues resulting in inflammation.

Parts of the body affected include: the joints, skin, kidneys, heart, lungs, blood vessels, and brain.

Systemic Lupus ErythematosusPeak age of onset is 20 to 40 years of

age.Found more frequently in women.Has both genetic and environmental

factors.Often difficult to diagnose.“Great imitator” as it mimics or is

mistaken for other illnesses.Can be fatal but survival rates

increasing.

SLE Clinical SignsExtremely diverse and nonspecific.Joint involvement most frequent

signs are polyarthralgia and arthritis which occur in 90% of patients.

Skin manifestations next most common.

Erythematosus rash may appear.Most classic is butterfly rash.

Symptoms of SLE

SLE Butterfly Rash The source of the name "lupus"

is unclear. All explanations originate with the characteristic butterfly-shaped malar rash that the disease classically exhibits across the nose and cheeks.

Various accounts, some doctors thought the rash resembled a wolf pattern. In other accounts doctors thought that the rash, which was often more severe in earlier centuries, created lesions that resembled wolf bites or scratches.

Stranger still, is the account that the term "Lupus" didn't come from latin at all, but from the term for a French style of mask which women reportedly wore to conceal the rash on their faces

SLE Clinical SignsRenal involvement very common.

Caused by deposition of immune complexes in kidney tissue.

Leads to renal failure, most common cause of death.

Other systemic effects:CardiacCentral nervous systemLiverHematologic abnormalities

Immunologic FindingsLupus Erythematosus (LE) cell, neutrophil

which has engulfed the antibody-coated nucleus of another cell.First classic test to aid in diagnosis.Not utilized anymore, may still see in older

references.Over activity of B cells main immunologic

characteristic.Antinuclear antibodies produced.More than 28 antibodies associated with LE have

been identified.Level of antibody production correlates with

severity of symptoms.Estrogen enhance B cell activation.

LE Cell"LE cell" test which has value only in demonstrating how the

concept of autoantibodies work. Pink blobs are denatured nuclei.Two in this slid, one being phagocytosed in the center by a

PMN.This test is not nearly as sensitive as the ANA which has

supplanted the LE cell test. Therefore, NEVER order an LE cell test. [Image contributed by Elizabeth Hammond, MD, University of Utah]

Immunologic FindingsDecrease in absolute number of T

cellsAccumulation of immune

complexes with activation of complement lead to kidney damage.

Drug induced lupus may occur, discontinue drug, symptoms usually disappear.

Laboratory DiagnosisScreening test for anti-nuclear

antibodies (ANA) first test done.Antibodies directed against nuclear

material of cells.Flourescent anti-nuclear antibody

(FANA) most widely used, extremely sensitive, low diagnostic specificity.

Animal or human cells fixed to slide.Add patient serum and incubate.Wash to remove unreacted antibody.Add anti-human globulin labeled with

fluorescent tag or enzyme.

Antinuclear Antibody TestAntinuclear antibodies (ANA) are

autoantibodies against various cell nucleus antigens and are found in patients with autoimmune diseases such as SLE.

Some of ANA are considered to be useful for diagnosis of autoimmune diseases.

This picture illustrates the most common antigens used in the ANA

At the MLT level you will not be required to memorize.

ANAPatients antinuclear antibody titer of 1:40 and

characteristic multiorgan system involvement can be diagnosed with SLE without additional testing

Patients with antibody titer of 1:40 who fail to meet full clinical criteria should undergo additional testing including:Tests for antibody to doublestranded DNA antigenAntibody to Sm nuclear antigen.

Antinuclear antibody titer of less than 1:40 usually rules out systemic lupus erythematosus but patients with persistent, characteristic multisystem involvement may be evaluated for possible antinuclear antibody–negative disease.

ANAPatterns of reactivity:

Homogenous-entire nucleus stainedPeripheral-rim of nucleus stainedSpeckled-spots of stain throughout nucleus

Nucleolar-nucleolus only stainedFalse positives and negatives occur.

If positive, perform profile testing.

ANAFor the next exam you must be able to:

Name the 4 primary reactionsDescribe the 4 primary reactions seenIdentify the type of reaction in a photo

Homogeneous PatternSmooth, even staining of the nucleus

with or without apparent    masking of the nucleoli

Nucleolar23 or 46 (or some multiple of 46) bright

speckles or ovoid granules spread over the nucleus of interphase cells

PeripheralFluorescence is most intense at the

periphery of the nucleus with a large ring starting from the internal nuclear membrane and the rest of the nucleus showing weaker yet smooth staining.

SpeckledLarge speckles covering the whole

nucleoplasm, interconnected by a fine fluorescent network.

Anti-nuclear antibodies detected by FANADouble-stranded DNA (ds-DNA) antibodies are most

specific for SLE, correlate well with disease activity.Antihistone antibody second major antibody found

in SLE.Deoxyribonucleoprotein (DNP) antibody, responsible

for LE cell phenomena and available as a latex agglutination test.

Anti-Sm antibody, specific for LE.SS-A/Ro and SS-B/La antibodies, most common in

patients with cutaneous manifestations.Anti-nRNP detected in patients with SLE as well as

mixed connective tissue disease.Presence of antibodies not diagnostic, may be

present due to other diseases.

Anti-Nuclear Antibody by ImmunodiffusionUsed to determine specificity.Ouchterlony double diffusion most

frequently used to identify antibodies to: Sm, nRNP, SS-A/Ro, SS-B/La and others.

Test is not as sensitive but very specific.

Systemic Lupus Erythematosus

Extractable Nuclear Antigen Antibody to cytoplasmic and nuclear

components. Over 100 different antigens

described.It is associated with mixed connective

disease and SLE with particular features (arthritis, myositis, Raynaud's phenomenon - also association with HLA-DR4 and HLA-DQw8).

Extractable Nuclear Antigen ENA

Antiphospholipid AntibodiesAntiphospholipid antibodies may

be present and are of two types.Anticardiolipin.Lupus anticoagulant, if present, may cause spontaneous abortion and increase

Risk of clotting, platelet function may be affected.

TreatmentAspirin and anti-inflammatories for

fever and arthritis.Skin manifestations-anti-malarials

or topical steroids.Systemic corticosteroids for acute

fulminant lupus, lupus nephritis or central nervous system complications.

Five year survival rate is 80 to 90%.

Rheumatoid ArthritisChronic systemic inflammatory

disease primarily affecting the joints, but can affect heart, lung and blood vessels.

Women three more times as likely as men to have it.

Typically strikes at ages between 20 and 40, but can occur at any age.

The three major symptoms of arthritis are joint pain, inflammation, and stiffness.

Progress of disease varies.

ArthritisGroup of conditions involving damage to

the joints of the body.Over 100 different forms of arthritis.Will discuss the autoimmune type,

rheumatoid arthritis.

Clinical SignsDiagnosis based on criteria established

by American College of Rheumatologists, must have at least 4 of the following:Morning stiffness lasting 1 hour.Swelling of soft tissue around 3 or more

joints.Swelling of hand/wrist joints.Symmetric arthritis.Subcutaneous nodulesPositive test for rheumatoid factor.Xray evidence of joint erosion.

Clinical SignsSymptoms initially non-specific: malaise,

fever, weight loss, and transient joint pain.Morning stiffness and joint pain improve during

the day.Symmetric joint pain: knees, hips, elbows,

shoulders.Joint pain leads to muscle spasm, limits range of

motion, results in deformity.Approximately 25% of patients have nodules

over bones (necrotic areas), nodules can also be found in organs.

Certain bacteria may trigger RA due to certain proteins that possess antigens similar to those antigens found in joint, ie, molecular mimicry

Immunologic FindingsRheumatoid Factor (RF) is an IgM

antibody directed against the Fc portion of the IgG molecule, it is an anti-antibody.

Not specific for RA, found in other diseases.

Immune complexes form and activate complement and the inflammatory response.

Enzymatic destruction of cartilage is followed by abnormal growth of synovial cells, results in the formation of a pannus layer.

Rheumatoid Arthritis

Rheumatoid Arthritis

DiagnosisDiagnosis is based on:

Clinical findings.Radiographic findingsLaboratory testing.

Laboratory TestingRheumatoid Factor

IgM autoantibody directed against the Fc portion of the antibody molecule.

Detected by testing patient serum with red blood cells or latex particles coated with IgG, agglutination is a positive result.

Nephelometry and ELISA techniques are available to quantitate the RF.

Erythrocyte Sedimentation Rate (ESR) used to monitor inflammation.

C-Reactive protein (CRP) is utilized to monitor inflammation

TreatmentGoal to achieve lowest level of disease,

remission if possible, minimization of joint damage.

Rest and non-steroidal anti-inflammatory drugs control swelling and pain.

Substantial functional loss seen in 50% of patients within 5 years.

Slow acting anti-rheumatic drugs are coming into use but have side affects.

Joint replacement.

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