Unit 3 Autoimmunity
Part 2 Systemic Lupus Erythematosus
Part 3 Rheumatoid Arthritis
Terry Kotrla, MS, MT(ASCP)BB
Expectation
 Students are expected to know:
 Signs and symptoms, especially part of body affected
 Age and sex if appropriate
 Tests to diagnose
 Treatment
Systemic Lupus Erythematosus
 Chronic, 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 Erythematosus
 Peak 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 Signs
 Extremely 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 Signs
 Renal involvement very common.
 Caused by deposition of immune complexes in kidney
tissue.
 Leads to renal failure, most common cause of death.
 Other systemic effects:
 Cardiac
 Central nervous system
 Liver
 Hematologic abnormalities
Immunologic Findings
 Lupus 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 Findings
 Decrease in absolute number of T cells
 Accumulation of immune complexes with
activation of complement lead to kidney
damage.
 Drug induced lupus may occur, discontinue
drug, symptoms usually disappear.
Laboratory Diagnosis
 Screening 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 Test
 Antinuclear 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.
ANA
 Patients 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 antigen
 Antibody 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.
ANA
 Patterns of reactivity:
 Homogenous-entire nucleus stained
 Peripheral-rim of nucleus stained
 Speckled-spots of stain throughout
nucleus
 Nucleolar-nucleolus only stained
 False positives and negatives occur.
 If positive, perform profile testing.
ANA
 For the next exam you must be able to:
 Name the 4 primary reactions
 Describe the 4 primary reactions seen
 Identify the type of reaction in a photo
Homogeneous Pattern
 Smooth, even staining of the nucleus with or without
apparent masking of the nucleoli
Nucleolar
 23 or 46 (or some multiple of 46) bright speckles or
ovoid granules spread over the nucleus of interphase
cells
Peripheral
 Fluorescence 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.
Speckled
 Large speckles covering the whole nucleoplasm,
interconnected by a fine fluorescent network.
Anti-nuclear antibodies detected by FANA
 Double-stranded DNA (ds-DNA) antibodies are most specific for
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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
Immunodiffusion
 Used to determine specificity.
 Ouchterlony double diffusion most frequently
used to identify antibodies to: Sm, nRNP, SSA/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 Antibodies
 Antiphospholipid 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.
Treatment
 Aspirin 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 Arthritis
 Chronic 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.
Arthritis
 Group of conditions involving damage to the joints of the
body.
 Over 100 different forms of arthritis.
 Will discuss the autoimmune type, rheumatoid arthritis.
Clinical Signs
 Diagnosis 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 nodules
 Positive test for rheumatoid factor.
 Xray evidence of joint erosion.
Clinical Signs
 Symptoms 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 Findings
 Rheumatoid 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
Diagnosis
 Diagnosis is based on:
 Clinical findings.
 Radiographic findings
 Laboratory testing.
Laboratory Testing
 Rheumatoid 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
Treatment
 Goal to achieve lowest level of disease, remission if possible,
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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.
The End
 Write a question about anything you did not understand in
this unit.
 You may choose to ask a question about any of the
presentations required for viewing the next class period.
 WRITE YOUR ANSWERS TO THE 6 QUESTIONS
presented in this presentation on a sheet of paper and submit
when you walk in the door.