CHAPTER 2

Evaluation of the Patient

B. Laboratory Assessment
KERSTIN MOREHEAD, MD

䊏 Laboratory testing is often valuable for screening for indication for additional investigations directed at
disease, confirming diagnoses, establishing disease identifying the precise autoantibody leading to the
stage, determining prognosis, gauging disease ANA pattern.
activity, and following responses to therapy. 䊏 Among others, anti-Ro, -La, -Sm, and -RNP antibodies
䊏 The erythrocyte sedimentation rate (ESR) and C- may all result in a positive ANA. These autoantibod-
reactive protein (CRP) frequently correlate well with ies are associated with a range of different rheumatic
disease activity in inflammatory disorders. diseases.
䊏 Rheumatoid factor (RF) and anti-cyclic citrullinated 䊏 Positive immunofluorescence assays for antineutro-
peptide (anti-CCP) anti-bodies are helpful in diagnos- phil cytoplasmic antibodies (ANCA) should be
ing rheumatoid arthritis. The specificity of RF for confirmed by enzyme immunoassays for antibodies
rheumatoid arthritis is poor. directed specifically against two antigens: proteinase-
䊏 Antinuclear antibodies (ANA) are found in many 3 and myeloperoxidase.
patients with rheumatic diseases and in essentially all 䊏 Decreased serum complement levels usually indicate
patients with systemic lupus erythematosus (SLE) and a disease process mediated by immune complex
systemic sclerosis. Under the proper clinical condi- deposition within tissues.
tions, the finding of a positive ANA assay is an

Laboratory testing is an important part of the evalua- ERYTHROCYTE

tion for many patients with possible rheumatic diseases.
As the understanding of rheumatic disease progresses, SEDIMENTATION RATE
new biomarkers are developed and the utility of existing
ones is refined. Laboratory tests can be valuable guides Inflammatory stress alters hepatic synthesis of plasma
for screening, confirming diagnosis, establishing disease proteins. As a result, fibrinogen and immunoglobulin
stage, and prognosis, as well as for following disease levels increase during the acute phase response. When
activity and response to treatment. Because no single red blood cells (RBCs) interact with these proteins,
test can provide absolute certainty about diagnosis, they form clusters that sediment at a faster rate than
prognosis, or state of disease activity, however, results individual RBCs. In chronic states of inflammation,
must be interpreted in the context of the broader clini- decreased serum albumin and hematocrit levels also
cal picture. Sensitivity, specificity, positive and negative lead to increased rates of erythrocyte sedimentation.
predictive values, and likelihood ratios all warrant
careful consideration when interpreting the utility of
any test. Although laboratory testing has grown sub-
Method (Westergren)
stantially as an aid to clinical diagnosis and management Whole serum is anticoagulated with sodium citrate and
over the past several decades, treatment decisions are allowed to stand. After 1 hour, the distance in millime-
rarely based on the result of a single test alone. In addi- ters between the top of the tube and the erythrocyte
tion to appreciating the strengths and shortcomings of sediment is measured. The test is sensitive to handling
testing approaches, the clinician must also be aware of and temperature (1). Normal values are not adjusted for
the variability that often exists between different assay age or gender in most laboratories, yet these character-
methods and individual laboratories. In general, the istics have well-known (if erratic) influences on the ery-
most useful tests are those that are ordered to answer throcyte sedimentation rate (ESR). The ESR generally
well-defined questions. increases with age and is somewhat higher in women.
15
16 KERSTIN MOREHEAD

The upper limits of normal for a man is equal to the age does not exclude an inflammatory process. Moreover,
divided by 2; for a woman, add 10 to the age and divide other disease processes, including heart disease, infec-
by 2 (2). tion, and malignancy, can lead to CRP elevations, as can
obesity, diabetes, and cigarette smoking.
Interpretation
The ESR is sensitive for most types of inflammation,
but cannot distinguish if the underlying cause is infec- RHEUMATOID FACTOR
tious, inflammatory, or paraneoplastic (3). A normal
value may help to rule out inflammatory disease, but an Rheumatoid factor (RF) is an autoantibody that binds
increased ESR, especially if the increase is only moder- to the Fc region of human IgG. IgM is the most common
ate, can be confusing. In addition, the normalization of RF isotype, but IgG and IgA RF may also be detected
a high ESR often lags behind the resolution of inflam- in the serum (6).
mation, making it less than ideal for monitoring disease
activity. Along with normal elevation due to age and
gender, the ESR can be increased by any condition that Method
raises serum fibrinogen, such as diabetes, end-stage The latex fixation test measures only RF IgM by pre-
renal disease, and pregnancy. Conversely, the ESR can cipitating the antibody with IgG-coated latex particles
be lowered by congestive heart failure, sickled erythro- mixed with serial dilutions of serum. Titers greater than
cytes, and the presence of cryoglobulins. 1 : 20 are positive. Nephelometry and ELISA are able
to detect all three isotypes.
C-REACTIVE PROTEIN
The c-reactive protein (CRP) is an acute phase protein
Interpretation
synthesized in response to tissue injury. Serum CRP In established rheumatoid arthritis (RA), RF has a
levels change more quickly than the ESR; with sufficient sensitivity on the order of 70%. In early RA the sen-
stimulus, the CRP can increase within 4 to 6 hours and sitivity is somewhat lower, approximately 50%, as some
normalize within a week (4). The CRP is often measured patients seroconvert only after having clinical disease
simultaneously with (and sometimes in place of) the ESR for weeks or months. A positive RF assay, far from
as a general measure of inflammation. Although CRP specific for RA, can be found in many other autoim-
and ESR values tend to correspond with each other, mune diseases, mixed essential cryoglobulinemia (see
some patients’ disease processes appear to correlate cryoglobulinemia, below), chronic infections, sarcoid-
better with one measure or the other. osis, malignancy, and a small percentage of healthy
people. The IgA isotype has been linked to erosive
Method disease and to rheumatoid vasculitis, but its precise
clinical utility remains unclear. Higher titers of RF are
Specific antibodies to CRP allow direct quantification by
associated with more severe disease, but as a longitu-
a variety of means. Nephelometry uses antibodies to bind
dinal measure of disease activity RF fares poorly. CRP
target proteins and then measures the scatter of light by
values may be more reliable for monitoring disease
antigen–antibody complexes. The enzyme-linked immu-
activity (7).
nosorbant assay (ELISA) uses coated plates to form
antigen–antibody complexes. These complexes are
detected by addition of secondary antibodies labeled with
an enzyme that, when mixed with a substrate, produces ANTI-CYCLIC CITRULLINATED
color that is measured by spectrophotometry. Because PEPTIDE ANTIBODIES
the CRP is a stable serum protein and its measurement is
not affected by other serum components, it tends to be Anti-cyclic citrullinated peptide antibodies (ANTI-
less variable than the ESR. The CRP is affected by age CCP) are autoantibodies directed against the amino
and gender, as is the ESR (5). In general, levels <0.2 mg/ acids formed by the posttranslational modification of
dL are considered normal and levels >1 mg/dL are deemed arginine. Some investigators believe anti-CCP anti-
consistent with inflammation, but there is considerable bodies have a role in the pathogenesis of RA (8).
laboratory-to-laboratory variation.

Interpretation Method
Because a certain degree of injury is required before IgG anti-CCP are measured by ELISA using synthetic
CRP is synthesized, a normal or indeterminate value citrullinated peptides. Reference ranges vary (9).
 CHAPTER 2 • EVALUATION OF THE PATIENT 17

Interpretation that is positive for staining and the pattern of the

stain.
Anti-cyclic citrullinated peptide antibodies have a sen-
sitivity for RA that is similar to that of RF, but anti-CCP
antibodies are much more specific. These test charac- Interpretation
teristics lend considerable usefulness to anti-CCP anti- Aninuclear antibody assays are nearly universally posi-
bodies in the setting of seronegative patients suspected tive in SLE, to the extent that ANA-negative lupus is
of having RA, patients with other forms of connective virtually nonexistent. Patients with systemic sclerosis 2
tissue disease who are RF positive, and patients with (scleroderma) and many other connective tissue dis-
hepatitis C or other infections that are often associated eases are also ANA positive with a very high frequency,
with RF positivity. Anti-CCP antibodies are often often in high titers. Depending on the exact technique
detectable in early RA and, in some cases, antedate the used, up to 30% of healthy people may have a positive
onset of inflammatory synovitis. Although anti-CCP titer (11). The prevalence of positive ANAs increases
antibodies may be a better predictor of erosive disease in women and older people. A positive ANA is not
than is RF, they do not correlate with extra-articular specific for SLE or autoimmune disease, especially if it
disease. A positive anti-CCP combined with a positive is transient or in low titer.
RF IgM correlates strongly with radiographic progres-
sion. Anti-CCP levels are not useful in the longitudinal
monitoring of disease activity (10). Specific Autoantibodies
Autoantibodies directed against individual antigens
have increased specificity for particular diseases. Some
ANTINUCLEAR ANTIBODIES of these autoantibodies also predict disease severity
(Table 2B-2) (12). These are ordered separately from
Antinuclear antibodies (ANA) are a diverse group of the ANA test.
autoantibodies that react with antigens in the cell
nucleus. Different patterns reflect different nuclear
components including nucleic acid, histones, and cen-
tromeres (Table 2B-1).
ANTINEUTROPHIL
CYTOPLASMIC ANTIBODY
Method Antineutrophil cytoplasmic antibodies (ANCA) are
Hep-2 cells (a human tumor cell line) are incubated autoantibodies that react with the cytoplasmic granules
with serial dilutions of serum. Using immunofluores- of neutrophils. Two general staining patterns, cyto-
cence microscopy, labeled antihuman IgG is used as plasmic (C-ANCA) or perinuclear (P-ANCA) can be
a stain. The result reflects the highest serum dilution detected by immunofluorescence. In forms of systemic

TABLE 2B-1. ANTINUCLEAR ANTIBODY PATTERNS.

PATTERN NUCLEAR ANTIGEN CLINICAL ASSOCIATIONS

Homogenous Double-stranded DNA Systemic lupus erythematosus

Diffuse Histone Drug reaction

Systemic lupus erythematosus
Topoisomerase I Systemic sclerosis

Speckled Extractable nuclear antigens (Sm, RNP) Mixed connective tissue disease
Systemic lupus erythematosus
Ro-SSA/La-SSB Sjögren’s syndrome
Other Poly/dermatomyositis
Various autoimmune diseases
Infection
Neoplasia

Nucleolar RNA-associated antigens Systemic sclerosis

Peripheral Double-stranded DNA Systemic lupus erythematosus

Centromere Centromere Limited systemic sclerosis

18 KERSTIN MOREHEAD

TABLE 2B-2. AUTOANTIBODIES IN RHEUMATIC DISEASES.

TYPE DESCRIPTION CLINICAL ASSOCIATION

Anti-dsDNA Antibodies to double-stranded DNA High specificity for SLE

Often correlates with more active, more severe disease
ELISA test is very sensitive and can be positive in other diseases,
normal people

Anti-histone Five major types exist SLE, drug-induced SLE, other autoimmune disease
SLE patients will likely be positive for other autoantibodies as well

Anti-ENA Sm (Smith) High specificity for SLE

RNP (ribonucleoprotein) Mixed connective tissue disease
RNA–protein complexes Higher prevalence in African American and Asian patients

Anti-SSA (Ro) Ribonucleoproteins SLE (especially subacute cutaneous lupus), neonatal lupus, Sjögren’s
syndrome

Anti-SSB (La) Ribonucleoproteins Sjögren’s syndrome, SLE, neonatal SLE

Anti-centromere Antibody to centromere/kinetochore region Limited scleroderma

of chromosome High rate of pulmonary hypertension
Primary biliary sclerosis

Anti-Scl 70 Antibodies to DNA topoisomerase 1 Diffuse scleroderma

Risk of pulmonary fibrosis

Anti-Jo-1 Antibody to histidyl tRNA synthetase Poly/dermatomyositis

Patients tend to have interstitial lung disease, Raynaud’s
phenomenon, mechanic’s hands, arthritis
Typically resistant to treatment

Anti-SRP Antibody to signal recognition protein Cardiomyopathy

Poor prognosis

Anti-PM-Scl Antibody to nucleolar granular component Polymyositis/scleroderma overlap syndrome

Anti-Mi-2 Antibodies to a nucleolar antigen of Dermatomyositis

unknown function Favorable prognosis

vasculitis, such as Wegener’s granulomatosis, micro- One common laboratory approach is to screen with
scopic polyangiitis, and the Churg–Strauss syndrome, ethanol-fixed cells and to perform assays on formalin-
these patterns reflect autoantibodies to two lyzosomal fixed cells if immunofluorescence is observed on screen-
granule enzymes: serine protease-3 (PR3) and myelo- ing. Increasingly reliable ELISA assays for the detection
peroxidase (MPO), respectively. Upon immunofluores- of both PR3 and MPO have been available since the
cence testing of sera, many patients with other forms early 1990s. For optimal clinical utility, any positive
of inflammatory disease (e.g., SLE, autoimmune hepa- immunofluorescence assay should be confirmed by the
titis, inflammatory bowel disease) have positive ANCA performance of anti-PR3 and -MPO ELISAs.
assays. ELISA testing in such patients, however, reveals
antibody specificities for antigens other than PR3 and
MPO. ANCA directed against PR3 and MPO are
Interpretation
termed PR3-ANCA and MPO-ANCA, respectively. The combination of C-ANCA and PR3-ANCA has a
high positive predictive value for ANCA-associated
vasculitis, particularly Wegener’s granulomatosis. Simi-
Method larly, the combination of P-ANCA and MPO-ANCA
To identify C- and P-ANCA patterns of immunofluo- has a high positive predictive value for microscopic
rescence, ethanol- or formalin-fixed human neutrophils polyangiitis. (For further discussion of the role of ANCA
are coated with the patient’s serum and stained with assays in these diseases and in the Churg–Strauss syn-
labeled anti-IgG. Formalin fixation is preferred because drome, please see Chapter 21C.)
the presence of antinuclear antibodies may cause a The more active and extensive the vasculitis, the
false-positive P-ANCA pattern on ethanol-fixed cells. more likely are ANCA assays to be positive. ANCA
 CHAPTER 2 • EVALUATION OF THE PATIENT 19

titers often normalize with treatment but do not always indicate the presence of cryoglobulins. Unfortunately,
do so, even if clinical remissions are achieved. Some the correlations between changes in complement levels
data suggest that a persistent rise in ANCA titer or and disease activity are poor. In addition, hypocomple-
return of ANCA positivity heralds an increased risk of mentemia may also be secondary to nonrheumatic
recurrent disease, but neither persistently positive diseases, notably subacute bacterial endocarditis
ANCA tests nor rising ANCA titers provide reliable and poststreptococcal glomerulonephritis (15). Low or
information about the timing of a disease flare. Treat- undetectable CH50 may indicate a deficiency of one or
ment decisions in ANCA-associated vasculitis are never more complement components. Patients with genetic 2
based entirely ANCA assay result. Moreover, positive deficiencies of early complement components (C1–C4)
ANCA tests may be caused by infection, drugs (particu- are at increased risk for developing immune-complex
larly thyroid medications such as propylthiouracil), and, diseases (16), particularly some forms of SLE.
as noted, other autoimmune diseases. Thus, under most
clinical circumstances, tissue biopsy remains the gold
standard for diagnosis (13). CRYOGLOBULINS
Cryoglobulins are immunoglobulins that precipitate
COMPLEMENT reversibly at cold temperatures. In a variety of diseases,
cryoglobulins often bind with complement proteins and
The complement cascade is a tightly regulated complex other peptides to form immune complexes. Based on
of proenzymes, regulatory proteins, and cell-surface their composition, cryoglobulins are classified into three
receptors that mediate and augment both of comple- types. Type I cryoglobulins are monoclonal immuno-
ment the humoral and cellular immune response. Acti- globulins, frequently of the IgM isotype. Type II cryo-
vation by antigen–immune complexes, bacterial surface globulins are a mixture of polyclonal IgGs and
proteins, and polysaccharides begins a fixed sequence monoclonal IgM. Type III cryoglobulins are a combina-
of reactions that lead to increased vascular permeabil- tion of polyclonal IgGs and polyclonal IgMs. In both
ity, chemotaxis, cell lysis, antigen–immune complex type II and type III cryoglobulinemia, the IgM compo-
clearance, and opsonization. The classical pathway (C1, nent has RF activity (i.e., it binds to the Fc portion of
C4, C2), the alternative pathway (factors B, D, and IgG), accounting for the fact that essentially all patients
properdin), and the mannose-binding lectin pathway all with these disorders are RF positive (often creating
share the final step of cleaving C3. The released product confusion in diagnosis with RA) (17).
(C3b) then induces formation of the terminal mem-
brane attack complex (C5–C9) (14).
Method
For proper collection of cryoglobulins, careful attention
Method to detail and preparation in advance are required.
Serum levels of individual components such as C3 and Whole blood must be drawn and maintained at body
C4 are measured by ELISA and nephelometry. The temperature until it coagulates. The sample is then cen-
plasma total hemolytic complement assay, or CH50, trifuged and the clot removed. The remaining serum is
assesses the functional integrity of the classical pathway. allowed to stand at 4°C for up to several days until
Serum is diluted and added to sheep antibody–coated precipitation is observed. The sample is spun again and
RBCs. The value reported is the reciprocal of the highest the cryocrit is measure in a calibrated tube. Isotype and
dilution able to lyse 50% of the RBCs. clonality are established by various immunochemical
techniques.
Interpretation
Decreased serum levels of individual components, espe-
Interpretation
cially C3 and C4, correlate with the increased consump- Cryoglobulins are not specific for any one disease. Type
tion observed in active immune complex mediated I cryoglobulins do not activate the complement cascade
disease, for example, SLE. In contrast, most inflamma- and are therefore associated with normal complement
tory disorders that are not associated with immune levels. They are linked to lymphoproliferative disor-
complex deposition demonstrate elevated levels of ders, malignancies, and hyperviscosity syndromes, and
complement because these proteins are acute phase often associated with sludging in the small vasculature
reactants. Hypocomplementemia, though useful in nar- of the extremities, eye, or brain. Type II and type III
rowing the differential diagnosis, is generally not spe- cryoglobulins, able to bind complement, are associated
cific for any particular disease. C4 levels that are with hepatitis C virus infections and a syndrome of
disproportionately low compared to those of C3 may small vessel vasculitis (see Chapter 21D) (18).
20 KERSTIN MOREHEAD

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