Antinuclear antibodies

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Antinuclear antibodies

Autoantibodies that attack substances found in the center, or nucleus, of all cells.

Antibodies, Antinuclear, Anti-DNA, Anticentromere, Antiextractable Nuclear Antigen, Anti-Jo, and Antiscleroderma

Synonym/acronym: Antinuclear antibodies (ANA), anti-DNA (anti-ds DNA), antiextractable nuclear antigens (anti-ENA, ribonucleoprotein [RNP], Smith [Sm], SS-A/Ro, SS-B/La), anti-Jo (antihistidyl transfer RNA [tRNA] synthase), and antiscleroderma (progressive systemic sclerosis [PSS] antibody, Scl-70 antibody, topoisomerase I antibody).

Common use

To diagnose multiple systemic autoimmune disorders; primarily used for diagnosing systemic lupus erythematosus (SLE).

Specimen

Serum (3 mL) collected in a red-top tube.

Normal findings

(Method: Indirect fluorescent antibody for ANA and anticentromere; Immunoassay multiplex flow for anti-DNA, ENA, Scl-70, and Jo-1)

ANA and anticentromere: Titer of 1:40 or less. Anti-ENA, Jo-1, and anti-Scl-70: Negative. Reference ranges for anti-DNA, anti-ENA, anti-Scl-70, and anti-Jo-1 vary widely due to differences in methods and the testing laboratory should be consulted directly.

Anti-DNA
NegativeLess than 5 international units
Indeterminate5–9 international units
PositiveGreater than 9 international units

Description

Antinuclear antibodies (ANA) are autoantibodies mainly located in the nucleus of affected cells. The presence of ANA indicates SLE, related collagen vascular diseases, and immune complex diseases. Antibodies against cellular DNA are strongly associated with SLE. Anticentromere antibodies are a subset of ANA. Their presence is strongly associated with CREST syndrome (calcinosis, Raynaud’s phenomenon, esophageal dysfunction, sclerodactyly, and telangiectasia). Women are much more likely than men to be diagnosed with SLE. Jo-1 is an autoantibody found in the sera of some ANA-positive patients. Compared to the presence of other autoantibodies, the presence of Jo-1 suggests a more aggressive course and a higher risk of mortality. The clinical effects of this autoantibody include acute onset fever, dry and crackled skin on the hands, Raynaud’s phenomenon, and arthritis. The extractable nuclear antigens (ENAs) include ribonucleoprotein (RNP), Smith (Sm), SS-A/Ro, and SS-B/La antigens. ENAs and antibodies to them are found in various combinations in individuals with combinations of overlapping rheumatologic symptoms. The American College of Rheumatology’s current criteria includes a list of 11 signs and/or symptoms to assist in differentiating lupus from similar diseases. The patient should have four or more of these to establish suspicion of lupus; the symptoms do not have to manifest at the same time: malar rash (rash over the cheeks, sometimes described as a butterfly rash), discoid rash (red raised patches), photosensitivity (exposure resulting in development of or increase in skin rash), oral ulcers, nonerosive arthritis involving two or more peripheral joints, pleuritis or pericarditis, renal disorder (as evidenced by excessive protein in urine or the presence of casts in the urine), neurological disorder (seizures or psychosis in the absence of drugs known to cause these effects), hematological disorder (hemolytic anemia, leukopenia, lymphopenia, thrombocytopenia where the leukopenia or lymphopenia occurs on more than two occasions and the thrombocytopenia occurs in the absence of drugs known to cause it), positive ANA in the absence of a drug known to induce lupus, or immunological disorder (evidenced by positive anti-ds DNA, positive anti-Sm, positive antiphospholipid such as anticardiolipin antibody, positive lupus anticoagulant test, or a false-positive serological syphilis test, known to be positive for at least 6 months and confirmed to be falsely positive by a negative Treponema pallidum immobilization or FTA-ABS).

This procedure is contraindicated for

    N/A

Indications

  • Assist in the diagnosis and evaluation of SLE
  • Assist in the diagnosis and evaluation of suspected immune disorders, such as rheumatoid arthritis, systemic sclerosis, polymyositis, Raynaud’s syndrome, scleroderma, Sjögren’s syndrome, and mixed connective tissue disease
  • Assist in the diagnosis and evaluation of idiopathic inflammatory myopathies

Potential diagnosis

ANA Pattern*Associated AntibodyAssociated Condition
Rim and/or homogeneousDouble-stranded DNASLE
Single- or double-stranded DNA
HomogeneousHistonesSLE
SpeckledSm (Smith) antibodySLE, mixed connective tissue disease, Raynaud’s scleroderma, Sjögren’s syndrome
RNP*Mixed connective tissue disease, various rheumatoid conditions
SS-B/La, SS-A/RoVarious rheumatoid conditions
Diffuse speckled with positive mitotic figuresCentromerePSS with CREST, Raynaud’s
NucleolarNucleolar, RNPScleroderma, CREST
*ANA patterns are helpful in that certain conditions are frequently associated with specific patterns. RNP = ribonucleoprotein.

Increased in

  • Anti-Jo-1 is associated with dermatomyositis, idiopathic inflammatory myopathies, and polymyositis
  • ANA is associated with drug-induced lupus erythematosus
  • ANA is associated with lupoid hepatitis
  • ANA is associated with mixed connective tissue disease
  • ANA is associated with polymyositis
  • ANA is associated with progressive systemic sclerosis
  • ANA is associated with Raynaud’s syndrome
  • ANA is associated with rheumatoid arthritis
  • ANA is associated with Sjögren’s syndrome
  • ANA and anti-DNA are associated with SLE
  • Anti-RNP is associated with mixed connective tissue disease
  • Anti-Scl 70 is associated with progressive systemic sclerosis and scleroderma
  • Anti-SS-A and anti-SS-B are helpful in antinuclear antibody (ANA)–negative cases of SLE
  • Anti-SS-A/ANA–positive, anti-SS-B–negative patients are likely to have nephritis
  • Anti-SS-A/anti-SS-B–positive sera are found in patients with neonatal lupus
  • Anti-SS-A–positive patients may also have antibodies associated with antiphospholipid syndrome
  • Anti-SS-A/La is associated with primary Sjögren’s syndrome
  • Anti-SS-A/Ro is a predictor of congenital heart block in neonates born to mothers with SLE
  • Anti-SS-A/Ro–positive patients have photosensitivity

Decreased in

    N/A

Critical findings

    N/A

Interfering factors

  • Drugs that may cause positive ANA results include acebutolol (diabetics), anticonvulsants (increases with concomitant administration of multiple antiepileptic drugs), carbamazepine, chlorpromazine, ethosuximide, hydralazine, isoniazid, methyldopa, oxyphenisatin, penicillins, phenytoin, primidone, procainamide, quinidine, and trimethadione.
  • A patient can have lupus and test ANA-negative.
  • Inability of the patient to cooperate or remain still during the procedure because of age, significant pain, or mental status may interfere with the test results.

Nursing Implications and Procedure

Potential nursing problems

ProblemSigns and SymptomsInterventions
Noncompliance, risk (Related to failure to comply with recommended therapeutic interventions; failure to accept diagnosis)Triggering an acute episode of lupus due to excessive sun exposure during peak periods Ensure the patient understands the diagnosis and disease process; discuss the risks of noncompliance on overall health
Skin (Related to rash and lesions associated with the disease process)Butterfly rash across bridge of nose; lesions on exposed areas of the skin; nose and mouth ulcers Avoid sun exposure during high-UV times; use a sunscreen with a UV protection greater than SPF 15 with sun exposure; reapply sunscreen frequently as needed; applies therapeutic creams or ointments to skin as prescribed by the physician
Protection (Related to open sores; decreased immune response; steroid use)Fever; tenderness, redness, warmth, drainage, and swelling of open sores Vigilant hand hygiene to protect from infection; monitor temperature and report any fever; monitor open sores for signs of infection; monitor white blood count; reverse isolation if immune system is compromised; adequate nutrition to promote healing
Body image (Related to physical changes associated with the disease process)Chronic erythematous coin-shaped raised patches (plaque) with scarring from older lesions; fixed erythema, flat or raised rash over the bridge of the nose and the cheekbones; expressions of feelings or concerns over visual physical changes; fear of rejection by others due to appearance Emphasize strengths; determine the patient’s expectations regarding appearance; identify the influence of the patient’s culture, religion, race, and gender on body image perceptions; monitor verbalization of self-criticism

Pretest

  • Positively identify the patient using at least two unique identifiers before providing care, treatment, or services.
  • Patient Teaching: Inform the patient this test can assist in evaluating immune system function.
  • Obtain a history of the patient’s complaints, including a list of known allergens, especially allergies or sensitivities to latex.
  • Obtain a history of the patient’s immune and musculoskeletal systems, symptoms, and results of previously performed laboratory tests and diagnostic and surgical procedures.
  • Obtain a list of the patient’s current medications, including herbs, nutritional supplements, and nutraceuticals (see Effects of Natural Products on Laboratory Values online at DavisPlus).
  • Review the procedure with the patient. Inform the patient that specimen collection takes approximately 5 to 10 min. Address concerns about pain and explain that there may be some discomfort during the venipuncture.
  • Sensitivity to social and cultural issues, as well as concern for modesty, is important in providing psychological support before, during, and after the procedure.
  • Note that there are no food, fluid, or medication restrictions unless by medical direction.

Intratest

  • Potential complications: N/A
  • Avoid the use of equipment containing latex if the patient has a history of allergic reaction to latex.
  • Instruct the patient to cooperate fully and to follow directions. Direct the patient to breathe normally and to avoid unnecessary movement.
  • Observe standard precautions, and follow the general guidelines in Patient Preparation and Specimen Collection. Positively identify the patient, and label the appropriate specimen container with the corresponding patient demographics, initials of the person collecting the specimen, date, and time of collection. Perform a venipuncture.
  • Remove the needle and apply direct pressure with dry gauze to stop bleeding. Observe/assess venipuncture site for bleeding or hematoma formation and secure gauze with adhesive bandage.
  • Promptly transport the specimen to the laboratory for processing and analysis.

Post-Test

  • Inform the patient that a report of the results will be made available to the requesting health-care provider (HCP), who will discuss the results with the patient.
  • Recognize anxiety related to test results, and be supportive of perceived loss of independence and fear of shortened life expectancy. Collagen and connective tissue diseases are chronic and, as such, they must be addressed on a continuous basis. Discuss the implications of abnormal test results on the patient’s lifestyle. Stress the importance of compliance to the treatment regimen. Instruct the patient with SLE to contact the HCP immediately if new symptoms present, including vague or common symptoms such as fever. Educate the patient regarding lifestyle changes that must be implemented to protect them from increased risk of infection and development of cardiovascular disease. Patients with lupus should be advised to avoid direct exposure to sunlight or other sources of UV light, like tanning beds (related to hypersensitivity of skin cells in people with lupus to UV light. The exact mechanism for this is not clearly understood, but it is believed that in people with lupus, damaged or dead skin cells are not sloughed as efficiently as occurs in normal individuals. It is also believed that cell contents released from damaged or dead skin cells may instigate an immune response leading to development of a skin rash. Sun exposure is known to damage skin; therefore, avoiding direct exposure reduces the amount of damage incurred.).
  • Patients wishing to become pregnant should discuss the possibility with their HCP. The stress of pregnancy and medication regimen may present significant risks to both mother and child; pregnancies should be carefully planned.
  • Patients with lupus are at increased risk for infection and should discuss the need for vaccinations with their HCP. Recommendations may include receiving vaccines during periods of remission.
  • Depending on the results of this procedure, additional testing may be performed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. Evaluate test results in relation to the patient’s symptoms and other tests performed.
  • Patient Education

    • Educate the patient regarding access to counseling services.
    • Educate the patient, as appropriate, regarding the importance of preventing infection, which is a significant cause of death in immunosuppressed individuals.
    • Reinforce information given by the patient’s HCP regarding further testing, treatment, or referral to another HCP.
    • Answer any questions or address any concerns voiced by the patient or family.
    • Provide teaching and information regarding the clinical implications of the test results, as appropriate.
    • Provide contact information, if desired, for the American College of Rheumatology (www.rheumatology.org), the Lupus Foundation of America (www.lupus.org), or the Arthritis Foundation (www.arthritis.org).
    • Provide education on caring for open sores to prevent infection.
    • Discuss the importance of adequate nutrients in supporting the immune system and preventing infection.
  • Expected Patient Outcomes

    • Knowledge
    • Describes the relationship between sun exposure and triggering an acute lupus episode
    • Explains that wearing loose, long-leg and long-sleeve clothing can enhance sun protection
    • Skills
    • Routinely demonstrates good hand hygiene skills
    • Demonstrates proficiency in the correct application of sunscreen
    • Attitude
    • Identifies personal strengths to enhance self-esteem
    • Discusses change in appearance in a positive manner

Related Monographs

  • Related tests include antibodies anticyclic citrullinated peptide, arthroscopy, biopsy kidney, biopsy skin, BMD, bone scan, chest x-ray, complement C3 and C4, complement total, CRP, creatinine, ESR, EMG, MRI musculoskeletal, procainamide, radiography bone, RF, synovial fluid analysis, and UA.
  • See the Immune and Musculoskeletal systems tables at the end of the book for related tests by body system.