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Antinuclear antibodies: When to

test and how to interpret findings
Order ANA assays only when clinical features suggest a
connective tissue disorder. Let ANA immunofluorescent
patterns direct additional testing decisions.
Practice
recommendation
Reserve antinuclear
antibody testing for instances
of clinically suggestive
connective tissue diseases
(CTD) and for assessing
CTD prognosis. It can also
be useful in monitoring
disease progression. C
Strength of recommendation (SOR)
A Good-quality patient-oriented
evidence
B Inconsistent or limited-quality
patient-oriented evidence
C Consensus, usual practice,

opinion, disease-oriented
evidence, case series
Habib U. Rehman, MB,

FRCPC, FRCPI, FRCP
(Glas), FACP
Department of Medicine,
Regina General Hospital,
Saskatchewan, Canada
habib31@sasktel.net
The author reported no
potential conflict of interest
relevant to this article.
ntinuclear antibodies (ANA) are a spectrum of auto

antibodies that react with various nuclear and cytoplasmic components of normal human cells. Their
detection is important in the diagnosis of some connective tissue diseases (CTD)eg, systemic lupus erythematosus (SLE),
Sjgrens syndrome (SS), scleroderma, polymyositis, or mixed
connective tissue disease (MCTD). Unfortunately, ANA tests
are often used indiscriminately in daily clinical practice.1
When is ANA testing warranted?

Indiscriminate use of ANA testing can yield positive results that
falsely point to CTD in a high proportion of patients and thereby
lead to further inappropriate testing and errant management decisions. To wit: The presence of ANA in the serum can be associated with any number of factors, such as genetic predisposition (eg,
through histocompatibility locus DR3), environmental agents (viruses, drugs), chronic infections, neoplasms, and advancing age.1
Therefore, the test should not be ordered in a patient with low pretest probability of CTD. Moreover, higher titers of ANA are more
clinically significant than lower titers. In one multicenter study,
31.7% of healthy individuals were ANA-positive at a serum dilution of 1:40, but only 5% were ANA-positive at a dilution of 1:160.2
What is the clinical significance
of different immunofluorescent patterns?
Immunofluorescent ANA testing not only determines if such
antibodies are present in a patients serum but also reveals informative antibody patterns. Five distinct patterns of fluorescence are possible and can help differentiate between various
CTDs (TABLE3):
1. Homogenous, in which the entire nucleus fluoresces, is
seen in SLE and discoid lupus erythematosus (DLE).
2. Rim, in which the nuclear perimeter fluoresces, is seen
most often in CREST (calcinosis, Raynauds phenom-
jfponline.com
Vol 64, No 1 | JANUARY 2015 | The Journal of Family Practice
E5
TABLE
Diagnostic significance of common

immunofluorescent ANA patterns3
When clinical
probability of
connective tissue
diseases is low,
the presence
of ANA in the
serum can
indicate chronic
infection,
neoplasm, or
advancing age.
ANA pattern
Specificity
Antigen
Disease association
Homogenous
Low
dsDNA
SLE
Histones
DLE, RA
Rim
High
Centromere
CREST, SLE
Speckled
Low
Ro/SS-A
SS
La/SS-B
SS
RNP
MCTD
Sm
SLE
Scl-70
Scleroderma
Nucleolar
Low
PM/Scl
Scleroderma
Cytoplasmic
Low
tRNA synthetases, Jo-1
Poly/dermatomyositis
Mitochondria
Primary biliary cirrhosis
Smooth muscle
Autoimmune hepatitis
ANA, antinuclear antibody; CREST, calcinosis, Raynauds phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia
syndrome; DLE, discoid lupus erythematosus; dsDNA, double-stranded DNA; MCTD, mixed connective tissue disease; RA,
rheumatoid arthritis; RNP, ribonucleoprotein; SLE, systemic lupus erythematosus; SS, Sjgrens syndrome; tRNA, transfer
ribonucleic acid.
enon, esophageal dysmotility, sclerodactyly, and telangiectasia) syndrome

and SLE.
3. Speckled, in which the nucleus fluoresces in a speckled pattern, can be
seen in a variety of CTDs, including
Sjgrens syndrome, MCTD, SLE, and
scleroderma.
4. Nucleolar, in which the nucleolus fluoresces, is associated with scleroderma.
5. Cytoplasmic, in which fluorescence
occurs outside the nucleus, typically
occurs with poly/dermatomyositis,
primary biliary cirrhosis, or autoimmune hepatitis.
What is the next step

if ANA is positive?
A positive ANA result warrants additional
studies to identify specific autoantibodies
suggested by the fluorescence pattern and by
a patients signs and symptoms.
Following up diagnostic clues
Most systemic autoimmune diseases have a
E6
highly characteristic profile of autoantibodies

to cellular antigens. A patients clinical features and ANA fluorescence pattern should
direct additional testing.
z Photosensitive butterfly rash, arthralgias/arthritis, pleuritic chest pain, fever of
unknown cause, and urine sediment consistent with nephritis point to a diagnosis of
SLE. Order an assay for anti-double-stranded
DNA (dsDNA) antibodies, which, if present,
confirm the diagnosis.4 Also order an assay
for anti-Sm antibodies, which are highly specific for SLE but found only in 30% to 40% of
SLE patients.4
z Raynauds phenomenon, skin hardening or thickening, stiffness and tightening
of the skin on the fingers, hands and forearms, tight and mask-like skin on the face, dry
cough, shortness of breath, and difficulty in
swallowing are features of scleroderma. If you
suspect this disorder, order an assay for antiScl-70 antibodies. These antibodies are highly
specific for scleroderma, but sensitivity of the
assay is only 15% to 20%.5
z Calcinosis, Raynauds phenomenon,
esophageal dysmotility, sclerodactyly, and te-
The Jour n a l of Fa mily Practice | J A NU A RY 2 0 1 5 | V o l 6 4 , N o 1
antinuclear antibodies: when to test
langiectasia indicate CREST syndrome. Anticentromere antibodies are highly specific for
CREST syndrome; sensitivity on assay is 50%
to 90%.6
z MCTD combines features of rheumatoid
arthritis, SLE, myositis, and scleroderma. Order an assay of anti-RNP (ribonucleoprotein)
antibodies. Although anti-RNP antibodies are
also found in 25% to 30% of patients with SLE,
they typically appear in the company of antiSm antibodies.7 Isolated high titers of anti-RNP
antibodies point to MCTD, and sensitivity on
assay is 100%.8 Their absence on testing, therefore, excludes the diagnosis of MCTD.
RNP, anti-Ro/SS-A, La/SS-B, and Sm are
also referred to as extractable nuclear antigens
(ENA). Assays of antibodies to ENA and antidsDNA are warranted only if the ANA assay
result is positive. It is rare to have a positive
anti-ENA antibody test (with the exception of
antibodies to cytoplasmic antigens) in the absence of a positive ANA test.9
z Dry eyes, dry mouth, joint pain and
swelling, and swelling of parotid glands point to
Sjgrens syndrome. Anti-Ro/SS-A and La/SS-B
antibodies are associated with Sjgrens syndrome, but are also found in seronegative SLE.10
Therefore, if patients with features suggestive of
SLE have a negative result on a dsDNA antibody assay, test for anti-Ro/SS-A and La/SS-B
antibodies.
zMuscle weakness and soreness, purplish discoloration of the upper eyelids, and
purplish-red discoloration of the knuckles
suggest dermatomyositis. Muscle biopsy and
electromyography will clinch the diagnosis.
Also test for antiJo-1 antibodies, which are
associated with pulmonary involvement in
polymyositis.11
ANAs continuing role

prognosis and disease activity
Besides confirming a diagnosis of CTD in patients with suggestive clinical features, ANA
testing serves 2 additional purposes: to help
determine a patients prognosis and to monitor
CTD activity. Consider the following:
Patients with Sjgrens syndrome who
test positive for anti-Ro/SS-A antibodies have aggressive, extra-glandular disease that can cause vasculitis, purpura,
lymphadenopathy, leukopenia, and
thrombocytopenia.12
The presence of anti-Ro/SS-A in the circulation of pregnant women with SLE
confers a higher risk of neonatal lupus
erythematosus and of congenital heart
block in their newborns.13
Severe interstitial lung disease is frequently found in scleroderma patients
who test positive for anti-Scl-70.14 Antibodies to aminoacyl-tRNA synthetasesincluding antiJo-1, as mentioned
earlierare associated with pulmonary
involvement in polymyositis patients.11
A positive ANA test result in Raynauds
phenomenon increases the likelihood
that the patient will develop a systemic
rheumatic disease; a negative result reduces this likelihood.15
While the ANA test is not useful for diagnosing juvenile chronic arthritis (JCA), it
is useful to test for ANA in patients with
known JCA. A positive test result should
prompt screening for uveitis.16
An ANA test is not necessary for diagnosing antiphospholipid antibody syndrome
(APS). However, the presence of ANA in a
patient with APS increases the likelihood
that APS is secondary to SLE.17
Monitoring disease activity
Documenting titers of anti-dsDNA antibodies may help in monitoring the disease activity
of SLE in some patients. However, changes in
titers of anti-dsDNA should be interpreted in
the clinical context of the SLE Disease Activity
Index.18
JFP
Think
systemic lupus
erythematosus
when a
patient has a
photosensitive
butterfly rash,
arthralgia,
pleuritic chest
pain, fever, or
urine sediment
consistent with
nephritis.
Correspondence
Habib U. Rehman, MB, Department of Medicine, Regina

QuAppelle Health Region, Regina General Hospital,
144014th Avenue, Regina, SK, S4P 0W5, Canada;
habib31@sasktel.net
References
1. Volkmann ER, Taylor M, Ben-Artzi A. Using the antinuclear
antibody test to diagnose rheumatic disease: when does a positive test warrant further investigation? South Med J. 2012;105:
100-104.
2. Giannouli E, Chatzidimitriou D, Gerou S, et al. Frequency and
specificity of antibodies against nuclear and cytoplasmic antigens in healthy individuals by classic and new methods. Clin
Rheumatol. 2013;32:1541-1546.
3. OSullivan M, McLean-Tooke A, Loh RK. Antinuclear antibody
test. Aust Fam Physician. 2013;42:718-721.
4. Kurien BT, Scofield RH. Autoantibody determination in the
diagnosis of systemic lupus erythematosus. Scand J Immunol.
2006;64:227-235.
c o nti nu ed
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E7
E8
5. Basu D, Reveille JD. Ant-scl-70. Autoimmunity. 2005;38:

65-72.
verse outcomes in primary Sjogrens syndrome: identification

of prognostic factors. Rheumatology. 2007;46:1359-1362.
6. Caramaschi P, Biasi D, Manzo T, et al. Anticentromere antibodyclinical associations. A study of 44 patients. Rheumatol
Int. 1995;14:253-255.
13. Lindop R, Arentz G, Thurgood LA, et al. Pathogenicity and proteomic signatures of autoantibodies to Ro and La. Immunol Cell
Biol. 2012;90:304-309.
7. Migliorini P, Baldini C, Rocchi V, et al. Anti-Sm and anti-RNP

antibodies. Autoimmunity. 2005;38:47-54.
8. Alarcn-Segovia D, Cardiel MH. Comparison between 3 diagnostic criteria for mixed connective tissue disease. Study of 593
patients. J Rheumatol. 1989;16:328-334.
9. Phan TG, Wong RC, Adelstein S. Autoantibodies to extractable
nuclear antigens: making detection and interpretation more
meaningful. Clin Diagn Lab Immunol. 2002;9:1-7.
10. Cross LS, Aslam A, Misbah SA. Antinuclear antibody-negative
lupus as a distinct diagnostic entitydoes it no longer exist?
QJM. 2004;97:303-308.
11. Miller FW, Waite KA, Biswat T, et al. The role of an autoantigen,
histidyl-tRNA synthetase, in the induction and maintenance of
autoimmunity. Proc Natl Acad Sci USA. 1990;87:9933-9937.
12. Brito-Zern P, Ramos-Casals M, Bove A, et al. Predicting ad-
14. Steen VD. Autoantibodies in systemic sclerosis. Semin Arthritis

Rheum. 2005;35:35-42.
15. Spencer-Green G. Outcomes in primary Raynaud phenomenon:
a meta-analysis of the frequency, rates, and predictors of transition to secondary diseases. Arch Intern Med. 1998;158:595-600.
16. Grassi A, Corona F, Casellato A, et al. Prevalence and outcome
of juvenile idiopathic arthritis-associated uveitis and relation to
articular disease. J Rheumatol. 2007;34:1139-1145.
17. Petri M. Diagnosis of antiphospholipid antibody syndrome.
Rheum Dis Clin North Am. 1994;20:443.
18. Kavanaugh A, Tomar R, Reveille J, et al. Guidelines for clinical
use of the antinuclear antibody test and tests for specific autoantibodies to nuclear antigens. American College of Pathologists. Arch Pathol Lab Med. 2000;124:71-81.
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What are the different patterns seen on ANA testing and what conditions are they associated with?

What are the different patterns seen on ANA testing and what conditions are they associated with?

What are some appropriate uses and limitations of ANA testing according to the article?

What are some appropriate uses and limitations of ANA testing according to the article?

Online

Antinuclear antibodies: When to

C Consensus, usual practice,

Habib U. Rehman, MB,

ntinuclear antibodies (ANA) are a spectrum of auto

When is ANA testing warranted?

Vol 64, No 1 | JANUARY 2015 | The Journal of Family Practice

Diagnostic significance of common

tRNA synthetases, Jo-1

Primary biliary cirrhosis

enon, esophageal dysmotility, sclerodactyly, and telangiectasia) syndrome

What is the next step

highly characteristic profile of autoantibodies

The Jour n a l of Fa mily Practice | J A NU A RY 2 0 1 5 | V o l 6 4 , N o 1

antinuclear antibodies: when to test

ANAs continuing role

Habib U. Rehman, MB, Department of Medicine, Regina

Vol 64, No 1 | JANUARY 2015 | The Journal of Family Practice

5. Basu D, Reveille JD. Ant-scl-70. Autoimmunity. 2005;38:

verse outcomes in primary Sjogrens syndrome: identification

7. Migliorini P, Baldini C, Rocchi V, et al. Anti-Sm and anti-RNP

14. Steen VD. Autoantibodies in systemic sclerosis. Semin Arthritis

The Jour n a l of Fa mily Practice | J A NU A RY 2 0 1 5 | V o l 6 4 , N o 1

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C Consensus, usual practice,

5. Basu D, Reveille JD. Ant-scl-70. Autoimmunity. 2005;38:

7. Migliorini P, Baldini C, Rocchi V, et al. Anti-Sm and anti-RNP

14. Steen VD. Autoantibodies in systemic sclerosis. Semin Arthritis