Unit 3

Autoimmune Disorders

MLAB 1335 – Immunology

Part Two – Systemic Autoimmune Disease – Lupus and ANA
 Systemic Autoimmune Diseases
• Autoimmune diseases that affect an antigen at many different
sites, involving several organs
• This session includes
• Systemic Lupus Erythematosus (SLE)
• ANA – What is the importance of this test?
• The expectation for students is to know the signs/symptoms
(body parts affected), age and sex affected (if appropriate), tests
to diagnose, and treatment
 Systemic Lupus Erythematosus (SLE)
• Chronic, systemic inflammatory disease caused by immune complex
formation – connection to type III hypersensitivity

• 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 (SLE)
• Peak age of onset is 20 to 40 years of age
• Found more frequently in women than men, by a ratio of 9 to 1
• Appears to originate from interactions of
• Environmental factors – UV light, certain meds, possibly infectious agents
• Genetic susceptibility
• Abnormalities within the immune system
• 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/Symptoms
• Extremely diverse and non-specific
• Fatigue, weight loss, malaise, fever, and anorexia
• Alternating relapses or flares with periods of remission
• Joint involvement most frequent signs are polyarthralgia and arthritis
which occur in 90% of patients.
• Usually the small joints of the hands, wrists, and knees
• Second most common sign is skin manifestation
• Occur in 80% of patients with SLE
• Erythematous rash may appear on any area exposed to UV light
• Classic – butterfly rash across the face
• Renal involvement is common
• From deposition of immune complexes in kidney tissue – renal failure
• Other systemic effects
• Cardiac, CNS, liver, and abnormal hematology results
SLE Clinical Signs/Symptoms
 LE Cell
• 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
• "LE cell" test which has value only in demonstrating how the concept of
autoantibodies work
• Pink blobs are denatured nuclei
 SLE Testing
• General lab testing includes
• CBC, platelet count, and UA
• May see decrease white count, anemia, and decreased platelets
• ESR elevated
• CRP low or normal
• C3 – may be low during flare ups of the disease – why?

• If SLE suspected, first test performed is the ANA

• Anti-nuclear antibodies are ab directed against antigens in the nuclei of
mammalian cells
• Present in over 95% of patients with active lupus
• Major marker for the disease
 ANA
• Not specific for SLE
• Can be found in other connective tissue diseases
• In other condition including cancer, chronic infections, and pregnancy
• 5% of healthy and 30% of elderly have positive ANAs
• Have different antigen specificities
• Nuclear ag that the ab are against include
• Double-stranded (ds)
• Single-stranded (ss)
• Deoxyribonucleic acid (DNA)
• Histones
• Nucleosomes
• Centromere proteins
• Extractable nuclear ag (also found in saline extract of mammalian tissues)
• Includes Sm ag, SS-A/Ro, SS-B/La ag
 Double-stranded DNA (dsDNA) Antibodies
• Most specific for SLE
• Mainly seen in these patients
• Levels correlate with disease activity
• But only found in 40 to 70% of patients
• Considered diagnostic for SLE
• Especially when with low complement component C3

• Produce a peripheral or homogeneous staining pattern on indirect

immunofluorescence
 FANA
• Most common testing is the FANA – fluorescent antinuclear antibody
testing
• Screening test to identify patients that have ANAs
• Uses commercially prepared slides with nucleated cells have
been fixed to the slide
• Principle of the test
• Microscope slide coated with Hep-2 cells
• Patient serum applied
• Wash
• Fluorescent-labeled anti-human Ig is added to detect bound
autoantibodies
• Wash
• Slide is read with fluorescent microscope
 Results of FANA
• Five typical patterns in nondividing cells may be viewed
• Titer of ≥ 160 is considered to be clinically significant
• Patterns
• Homogeneous (also known as diffuse) – uniform staining of he
entire nucleus. Associated with ab to dsDNA. Found in patients
with SLE
• Peripheral (rim or outline) – diffuse staining throughout the
nucleus, with greater staining intensity around the outer circle of
the nucleus – ab to dsDNA..patients with SLE
• Speckled – fluorescent specks throughout the nuclei. Found in
SLE, Sjogren’s syndrome, and systemic sclerosis
 Results of FANA
• Patterns continued
• Nucleolar – prominent staining of the nucleoli within the nuclei –
usually ab to RNA and RNP. Seen in patients with scleroderma
and other connective tissue disease
• Centromere – numerous speckles seen in the nuclei with most
cells having 46 speckles, (number of chromosomes) caused by
ab to proteins in the centromeres of the chromosomes. Found in
patients with CREST syndrome
 Patterns
• Homogeneous pattern
• Homogeneous (also known as diffuse) – uniform staining of he
entire nucleus. Associated with ab to dsDNA. Found in patients
with SLE
 Patterns
• Peripheral Pattern
• Peripheral (rim or outline) – diffuse staining throughout the
nucleus, with greater staining intensity around the outer circle of
the nucleus – ab to dsDNA…patients with SLE
 Patterns
• Speckled Pattern – fluorescent specks throughout the nuclei
connected by a fine fluorescent network. Found in SLE,
Sjogren’s syndrome, and systemic sclerosis
 Patterns
• Nucleolar Pattern– prominent staining of the nucleoli within the
nuclei – usually ab to RNA and RNP. Seen in patients with
scleroderma and other connective tissue disease
 Patterns
• Centromere Pattern – numerous speckles seen in the nuclei with
most cells having 46 speckles, (number of chromosomes)
caused by ab to proteins in the centromeres of the
chromosomes. Found in patients with CREST syndrome
 Patterns
• Mixed patterns may be observed
• Up to 5% of SLE patients may test negative
• FANA the gold standard for ANA testing
• Time consuming
• Major technical expertise
• Working towards automation
 Antiphospholipid Antibodies
• Antibodies to phospholipid alone or phospholipids attached to proteins
• Lupus anticoagulant antibody – one of the antiphospholipid antibodies
• Produces a prolonged PT and PTT, but
• Patients have an increased risk of clotting and spontaneous abortion
• May affect platelet function
• Found in 60% of those with SLE
• Also associated with deep-vein/arterial thrombosis, recurrent
pregnancy loss
 Treatment
• Aspirin and anti-inflammatories for fever and arthritis.
• Skin manifestations-anti-malarials or topical steroids.
• Systemic corticosteroids for
• acute fulminant (severe and sudden) lupus
• lupus nephritis
• central nervous system complications
• Five year survival rate, > 90%
• Most common cause of death is infection, followed by heart disease
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