It's all immune to me
IgM antibody directed against Fc portion of IgG immunoglobulin
Rheumatoid Factor - present in 70% of patients with rheumatoid arthritis
AntiCCP more specific
Antibody associated with CNS lupus and lupus hepatitis
Antiribosomal P
Sensitivity 30%, specificity in classic disease >80%
What is disease and antibody -
Acute disease onset, constitutional symptoms (eg, fever and weight loss), myositis, Raynaud phenomenon, mechanic's hands, arthritis that is generally nonerosive, and ILD
Antisynthetase syndrome, Anti Jo1
30-40% of patients with DM and PM have this constellation.
Mechanics hands - hyperkeratotitic fissured plaques
Approximate percentage of health population with positive low titer ANA
~33%
About one third of the healthy population has a low-titer (1:40) ANA, and 3% to 5% have a titer of 1:160 or more
-55 yoM in ICU intubated due to acute resp failure
-leg swelling, nonhealing skin ulcers. pain in joints. quit smoking 15 years ago
-Exam: normal vitals, synovitis, two necrotic ulcers on left leg and rightleg, 2+pitting edema
-Labs: positive ANCA with perinuclear pattern, 3+proteinuria. Biopsy of skin ulcer - nongranulomatous, necrotizing small vessel vasculitis with IF negative for immune complexes
-Rads: diffuse bilateral infiltrates
Diagnosis?
A. Granulomatosis with polyangiitis
B. IgA vasculitis
C. Microscopic polyangiitis
D. Rheumatoid vasculitis
E. Thbomangiitis obliterans
Microscopic polyangiitis; based on biopsy and clinical findings of lung disease, kidney failure, inflammaory arthritis
GPA: c-anca, also GRANULOMATOUS inflammation
IgA vasculitis: IgA deposition - HSP purpura
Rheumatoid vasculitis: positive RF, long term sequelae of RA
Thromboangiitis obliterans: small and medium vessel thrombosis in active smokers
Most specific test for SLE but does not correlate to disease activity
Anti-Smith
In lupus 30% sensitivity, 99% specificity
DOES NOT correlate to disease activity
Inflammatory marker produced by liver in response to IL-6 generated by leukocytes
CRP
In rheum processes CRP elevated 2-10 times ULN. If >10 consider non rheum process, mainly infection. Falsely elevated in obesity, artificially low with antibiotics
Name 3 drugs implicated drug induced lupus. also name the antibody
Anti-histone
Procainamide, Hydralazine, Minocycline, antithyroid, statins, CCBs, Thiazides, ACEi, TNFalpha inhibitors
Mild lupus symptoms resolve with discontinuation of offending agent
Name three conditions outside of SLE in which ANA can be positive
ANY autoimmune, infection, liver disease, malignancy, drug induced,thyroid disease, vitamin d deficiency
75 yoM with hx of hand joint pain, morning stiffness, lasts few minutes. Exam shows bony enlargement of PIP and DIP. ESR 22.
Rads: joint-space narrowing and osteophytes of multiple proximal and distal interphalangeal joints, and similar changes are seen in both first carpometacarpal joints; there are no erosions.
What is next step in TESTING?
a. Anti-cyclic citrullinated peptide antibodies
b. ANA
c. RF
d. Serum urate level
e. No further testing
No further testing
Most sensitive test for mixed connective tissue disease
Anti-U1-RNP
Raynaud phenomenon; arthritis; puffy fingers; sclerodactyly; serositis; esophageal dysmotility; myositis; interstitial lung disease; PAH; overlap syndrome
How do you adjust the upper limit of normal for ESR
Men: age/2
Women: (Age+10)/2
Elevated esrs seen in: inflammatory states, pregnancy, diabetes mellitus, and end-stage kidney disease. Levels >100 should raise concern for GCA, MM, cancer, overhwelming autoimmune process
How did they come up with the name "Anti Smith" antibody?
tradition of naming antigens after the person (Stephanie Smith) whose serum was initially used to identify and characterize the proteins
Anti-Sm antibodies are relatively insensitive but highly specific markers for SLE and generally remain positive, even when a patient has entered remission
Titers of this antibody often fluctuate with SLE disease activity
anti-dsDNA
32 year old dude with back pain
ESR 27
A plain anteroposterior radiograph of the pelvis shows fusion of the sacroiliac joints.
Which of the following is the most appropriate diagnostic test to perform next?
A. Anca
B. Anti-cyclic citrullinated peptide antibodies
C. ANA
D. HLA-B27 antigen
E. No additional testing
No additional testing
Patients with CREST are more likely to develop this in the presence of anticentromere antibodies
Pulmonary Hypertension
Anticentromere antibodies 10-30% sensitivity
history of asthma, nasal polyps, rhinitis, sinusitis, and/or atopy, glomerulonephritis. A prodromal phase consisting of arthralgia, myalgia, malaise, fever, and weight loss may occur. Peripheral and tissue eosinophilia.
Diagnosis and antibody?
Eosinophilic Granulomatosis with Polyangiitis, pANCA
This famous professional athlete is likely to be positive for anti-Ro and anti-La antibodies. Also name the syndrome.
Venus Williams, Sjogren syndrome
In a patient with lupus, this marker can project risk for developing lupus nephritis
anti-dsDNA, along with complement consumption
27 year old daycare worker. sudden onset joint pain and stiffness in fingers, wrists, knees ankles for 3 days. Prior to this had a febrile illness and rash that has resolved.
Exam: mild warmth and tenderness of 1st through 5th PIP and MCP bilaterally. Pain with ROM in knees and ankles
Which will confirm diagnosis?
A. ANA
B. HIV test
C. Parvo b19 testing
D. Rheumatoid factor
Parvob19
Parvovirus B19 infection should be suspected in patients with an acute onset of small-joint symmetric polyarthritis following a febrile illness with rash, who have exposure to children.
This antibody is associated with diffuse systemic sclerosis and scleroderma renal crisis
Anti RNA polymerase III
poor sensitivity, ok specificity but wide range
Patient is diagnosed with mixed cryoglobulinemia, what is major infectious association that she or he should be tested for?
HCV
Rheum joke:
If a nuclear weapon is used, who will survive?
SLE patients, because they have anti nuclear antibodies
these antibodies are frequently present in patients with SLE result in increased risk of thrombotic events and may be associated with false-positive RPR for syphilis
Antiphospholipid antibodies/lupus anticoagulant
Highest risk of thrombosis occurs in "triple positivity" - lupus anticoagulant, anti B2 glycoprotein, anticardiolipin
36 yoM with 2 month hx morning stiffness in hands, wrists, knees, feet lasting 90 mins. Feels better after hot shower and activity.
Exam: normal vitals. Tendernes and swelling of 2nd, 3rd, 5th MCP bilaterally. 2nd through 4th PIP bilaterally. Right wrist. Left knee.
Which of the following is the most appropriate diagnostic test to perform next?
A. Anti cyclic citrullinated peptide antibodies
B. HLA B27
C. Parvo IgG
D. Serum Urate
E. TSH
Anti-cyclic citrullianted peptide antibodies
This patient has a symmetric inflammatory polyarthritis. Anti-CCP antibodies have a sensitivity of 70%, similar to that of rheumatoid factor, but they have a much higher specificity than rheumatoid factor (95%)