Autoantibodies in Systemic Autoimmune Diseases K

umschlag_neutral.qxd 03.10.2007 10:53 Seite 1 ence for many years to come. testing continues to change, information this will be a useful and valuable refer- disease and associated autoantibodies. landscape of autoantibody the Although ensure fast and easy cross-reference between symptoms, a given autoimmune mune diseases will not be covered volume. in this Guide marks were inserted to autoimmune disease are listed. Systemic manifestations autoim- of organ-specific mune disorders as well as symptoms indicate that possible presence the of an alphabetical order in Part reference 1 of this guide. In Part 2, systemic autoim- Autoantibodies in systemic observed autoimmune diseases are described in diagnostic and prognostic tools for systemic patients with rheumatic diseases. of autoantibodiesstanding are that and interpreting being used as variety the nosis. This book and reference guide is intended to assist physician the in under- role in raisingimportant suspicion of evolving the disease and forecasting prog- single disease manifestation, detection the of serum autoantibodies can play an www.pabst-publishers.com ISBN 978-3-89967-420-0 autoimmune diseases. In case of limited diagnosis, prognostication,diagnosis, differential or monitoring of cance. Testing for for autoantibodies the can be helpful or necessary and clinical signifi- induction, effects, respect to specificity, their Autoantibodies are heterogeneous a very group of antibodies with (forme fruste) disease or a

Autoantibodies in Systemic Autoimmune Diseases K. Conrad, W. Schößler, F. Hiepe, M. J. Fritzler Karsten Conrad, Werner J. Fritzler Schößler, Falk Hiepe, Marvin Autoantibodies in Systemic Autoimmune Diseases AUTOANTIGENS, AUTOANTIBODIES, AUTOIMMUNITY A Diagnostic Reference Volume 2, second Edition – 2007 P

ABST 2nd edition 2nd Autoantibodies in Systemic Autoimmune Diseases A Diagnostic Reference

Karsten Conrad, Werner Schößler, Falk Hiepe, Marvin J. Fritzler

Gesellschaft zur Förderung der Immundiagnostik e.V. Dresden http://www.GFID-eV.de AUTOANTIGENS,AUTOANTIBODIES,AUTOIMMUNITY

Edited by: K. Conrad (Dresden, Germany) U. Sack (Leipzig, Germany) Vol. 2, second Edition – 2007

Authors Dr. Karsten Conrad Institute for Immunology Medical Faculty of the Technical University Dresden Fetscherstrasse 74 01307 Dresden, GERMANY Phone: +49 (0) 351-458-6540 Fax: +49 (0) 351-458-6308 E-mail: K [email protected]

Dr. Werner Schößler Rathenaustr. 12 16341 Panketal, GERMANY Fax: +49 (0) 30-983-119-94 E-mail: [email protected]

Prof. Dr. Falk Hiepe Charite´ University Hospital Department of Rheumatology & Clinical Immunology Schumannstraße 20/21 10117 Berlin, GERMANY Phone: +49 (0) 30-450-513012 Fax: +49 (0) 30-450-51392 E-mail: [email protected]

Marvin J. Fritzler, MD, PhD Professor of Medicine Arthritis Society Chair Faculty of Medicine University of Calgary Calgary, Alberta, CANADA Phone: +01 403-220-3533 Fax: +01 403-283-5666 E-mail: [email protected] Contents

Preface, 2nd edition...... XV Preface, 1st edition...... XVI NotesfortheUseofthisBook...... 1 Autoantibodies  Deﬁnitions and Characteristics ...... 3 Autoantibodies in the Diagnosis of Autoimmune Diseases ...... 4

Part 1 Autoantibodies in Systemic Autoimmune Diseases Alanyl-tRNA (tRNAAla)SynthetaseAntibodies...... 10 Alpha-ActininAntibodies...... 10 Alpha-EnolaseAntibodies...... 10 Alpha-FodrinAntibodies ...... 12 Aminoacyl-tRNASynthetaseAntibodies ...... 13 AnnexinVAntibodies...... 15 AntineutrophilCytoplasmicAntibodies(ANCA)...... 16 AntinuclearAntibodies(ANA)...... 19 ASE-1Antibodies...... 21 Asparaginyl-tRNA (tRNAAsp)SynthetaseAntibodies...... 21 AssemblyosomeAntibodies...... 22 AzurocidinAntibodies...... 22 Beta-FodrinAntibodies...... 24 Beta-2 Glycoprotein I (β2-GPI)Antibodies...... 24 BPIAntibodies...... 27 C1DAntibodies...... 28 C1qAntibodies...... 28 CADM-140Antibodies...... 30 CalpastatinAntibodies...... 31 CalreticulinAntibodies...... 32 cANCA(C-ANCA)...... 33 VI C

CardiolipinAntibodies...... 34 CathepsinGAntibodies...... 37 CCPAntibodies...... 38 CD16Antibodies...... 39 CENP-BAntibodies...... 40 CENP-CAntibodies...... 40 CENP-EAntibodies ...... 41 CENP-FAntibodies...... 42 CentrioleAntibodies...... 44 CentromereAntibodies...... 44 CentrophilinAntibodies...... 47 CentrosomeAntibodies...... 47 ChromatinAntibodies...... 49 ChromoAntibodies...... 50 CitrullinatedProtein/PeptideAntibodies...... 51 CoilinAntibodies...... 53 CollagenAntibodies...... 54 CRPAntibodies...... 56 Cryoglobulins...... 56 CytoplasmicLinkerProtein170(CLIP-170)Antibodies ...... 57 DEKAntibodies...... 58 Double-StrandedDNA(dsDNA)Antibodies...... 59 EEA-1Antibodies...... 62 EF1AAntibodies...... 63 EJAntibodies...... 64 ElastaseAntibodies...... 64 ENAAntibodies...... 64 EndothelialCellAntibodies...... 65 EPCRAntibodies...... 66 ExosomeAntibodies...... 67 FerAntibodies...... 67 FerritinAntibodies...... 67 FibrillarinAntibodies...... 68 Fibrillin1Antibodies...... 69 FibroblastAntibodies...... 70 FilaggrinAntibodies...... 70 Glutaminyl-tRNA (tRNAGlu)SynthetaseAntibodies...... 71 Glycyl-tRNA (tRNAGly)SynthetaseAntibodies...... 71 GM1Antibodies ...... 72 GolgiApparatusAntibodies...... 72 GuAntibodies...... 74 GWBAntibodies...... 74 C VII

HeatShockProtein(Hsp)Antibodies...... 76 Histidyl-tRNA (tRNAHis)Synthetase(HRS)Antibodies...... 77 HistoneAntibodies...... 77 HMGAntibodies...... 79 HsEg5Antibodies...... 80 5-HT4ReceptorAntibodies...... 80 HumanNeutrophilElastase(HNE)Antibodies...... 80 IFI16Antibodies...... 81 IgAAutoantibodies...... 82 Isoleucyl-tRNA (tRNAIle)SynthetaseAntibodies...... 83 JaAntibodies...... 83 Jo-1Antibodies...... 83 KeratinAntibodies(AKA)...... 85 KiAntibodies...... 86 KinectinAntibodies...... 87 KJAntibodies...... 87 KSAntibodies...... 88 KuAntibodies...... 88 L5/5S Antibodies ...... 90 L7Antibodies...... 91 L12Antibodies...... 91 LactoferrinAntibodies...... 91 LaminAntibodies...... 92 La/SS-BAntibodies...... 92 LECellFactor...... 95 LEDGF(LensEpithelialDerivedGrowthFactor)Antibodies...... 96 Leucyl-tRNA (tRNALeu)SynthetaseAntibodies...... 97 LipoproteinLipase(LPL)Antibodies...... 97 LupusAnticoagulant(LA)...... 98 LysosomeAntibodies...... 100 LysozymeAntibodies...... 101 Lysyl-tRNA (tRNALys)SynthetaseAntibodies...... 101 M3mAchR(M3R)Antibodies...... 101 MasAntibodies...... 101 MBLAntibodies...... 102 MCVAntibodies...... 102 Mi-2Antibodies...... 103 MidbodyAntibodies...... 105 MMPAntibodies...... 107 Mpp1Antibodies...... 107 Mpp10Antibodies...... 108 MSAAntibodies...... 108 VIII C

MyeloperoxidaseAntibodies...... 110 MyosinAntibodies...... 113 Nedd5Antibodies...... 113 NMDAReceptorAntibodies...... 114 NOR-90Antibodies...... 115 NucleolarAntibodies...... 117 NucleolinAntibodies...... 118 NucleophosminAntibodies...... 119 NucleosomeAntibodies...... 120 NuMAAntibodies...... 122 OJAntibodies...... 124 oxLDLAntibodies...... 124 pANCA(P-ANCA)...... 126 PCNAAntibodies...... 128 PDGFReceptor(PDGFR)Antibodies...... 129 PerinuclearFactors(PNF)...... 130 PhosphatidicAcid(PA)Antibodies...... 130 Phosphatidylcholine(PC)Antibodies...... 131 Phosphatidylethanolamine(PE)Antibodies...... 132 Phosphatidylinositol(PI)Antibodies...... 133 Phosphatidylserine(PS)Antibodies...... 134 Phospholipid(PL)Antibodies...... 135 PL-7Antibodies...... 139 PL-12Antibodies...... 140 PM-1Antibodies...... 141 PMS1Antibodies...... 142 PM/SclAntibodies...... 142 PM/Scl-75Antibodies...... 145 PM/Scl-100Antibodies...... 145 Poly(ADP-Ribose)Polymerase(PARP)Antibodies...... 145 ProteasomeAntibodies...... 146 Proteinase3Antibodies...... 147 ProteinCAntibodies...... 149 ProteinSAntibodies...... 150 ProthrombinAntibodies...... 151 RA33Antibodies...... 152 ReplicationProteinA(RPA)Antibodies...... 155 RheumatoidFactors(RF)...... 156 RibosomalAntibodies...... 157 RibosomalPProtein(RPP)Antibodies...... 159 RibosomalRNAProcessing(Rrp)ProteinAntibodies...... 161 RNAAntibodies...... 162 C IX

RNAHelicaseIIAntibodies...... 163 RNAHelicaseA(RHA)Antibodies...... 163 RNAP-IAntibodies...... 164 RNAP-IIAntibodies...... 164 RNAP-IIIAntibodies...... 164 RNAPolymerase(RNAP)Antibodies...... 164 Ro52Antibodies...... 166 Ro60Antibodies...... 167 Ro/SS-AAntibodies...... 167 28SrRNAAntibodies...... 172 S10Antibodies...... 172 SaAntibodies...... 172 SAPAntibodies...... 173 SCAntibodies...... 173 Scl-70Antibodies...... 173 Single-StrandedDNA(ssDNA)Antibodies...... 176 Sip1Antibodies...... 177 SmAntibodies...... 177 snoRNPAntibodies...... 179 snRNPAntibodies...... 179 SRProteinAntibodies...... 182 SRPAntibodies...... 182 SS-56Antibodies...... 184 SS-AAntibodies...... 185 SS-BAntibodies...... 185 ssDNAAntibodies...... 185 Threonyl-tRNA (tRNAThr)SynthetaseAntibodies...... 185 Th/ToAntibodies...... 185 ThrombomodulinAntibodies...... 186 TopoisomeraseIAntibodies...... 187 TopoisomeraseIIAntibodies...... 187 TrimethylguanosineAntibodies...... 188 U1-RNPAntibodies...... 188 U2-RNPAntibodies...... 189 U4/U6-RNPAntibodies...... 189 U5-RNPAntibodies...... 190 U7-RNPAntibodies...... 190 U11-RNPAntibodies...... 190 XC

Part 2 Systemic Autoimmune Diseases – Syndromes, Diagnostic Criteria, Symptoms Abortion,spontaneous...... 192 Acidosis,renal-tubular...... 192 Acro-Osteolysis...... 192 Addison’sdisease...... 192 Adrenocorticalfailure ...... 192 Aldolase,elevatedinplasma...... 192 Alopecia...... 192 Alveolitis...... 193 Amaurosisfugax ...... 193 ANCA-associatedvasculitis...... 193 Anemia ...... 193 Anti-Jo-1syndrome ...... 194 Antiphospholipidsyndrome(APS)...... 194 Anti-SRPsyndrome ...... 197 Anti-Synthetasesyndrome...... 197 Arthralgia...... 198 Arthritis...... 198 Behcetdisease...... 199 Bronchialasthma...... 199 Budd-Chiarisyndrome ...... 200 Butterﬂyrash...... 200

Calcinosiscutis...... 200 “Cardiomyopathy ...... 200 Catastrophic”APS...... 201 Cavernoussinusthrombosis ...... 202 Cerebralinfarction...... 202 Cerebralischemia...... 202 Chorea...... 202 Churg-Strausssyndrome(CSS)...... 203 Claudicationofextremities ...... 203 Claudicationofmasticatorymuscles...... 204 Cogan’ssyndrome ...... 204 Congenitalheartblock...... 204 Conjunctivitis...... 204 Connectivetissuediseases...... 205 Creatinekinase,elevatedinplasma...... 205 CRESTsyndrome ...... 205 Cryoglobulinemia ...... 206 Cryoglobulinemicnephropathy...... 206 C XI

Cryoglobulinemicpurpura ...... 206 Cryoglobulinemicvasculitis...... 206 Cutaneousleukocytoclasticvasculitis...... 207 Dementia,multi-infarct ...... 207 Dermatomyositis...... 207 Dermatomyositis,amyopathic...... 208 Discoidlupuserythematosus(DLE)...... 208 Drug-inducedlupus(DIL)...... 209 Eosinophilia...... 210 Epilepsy...... 210 Episcleritis...... 210 Erythema ...... 210 Esophagealdysfunction...... 210 Evanssyndrome ...... 211 FacialParesis ...... 211 Felty’ssyndrome ...... 211 Fingertipnecrosis...... 212 Giantcellarteritis...... 212 Glomerulonephritis ...... 212 Glomerulosclerosis...... 213 Goodpasture’sdisease ...... 213 Gottron’ssign...... 213 Guillain-Barresyndrome ...... 213 Headache ...... 213 Hemianopia...... 214 Hemorrhagicalveolitis...... 214 Henoch-Schönleinpurpura...... 214 Hepaticinfarction ...... 215 Hepatomegaly...... 215 Horton’sdisease...... 215 Hypereosinophilia ...... 215 Hypergammaglobulinemia ...... 216 Hypersensitivityvasculitis...... 216 Hypertension...... 216 Hypocomplementemicurticarialvasculitissyndrome(HUVS)..... 217 IgAnephropathy...... 218 Intestinalnecrosis ...... 218 Intracardiacthrombus...... 218 Juvenilechronicarthritis(JCA)...... 218 Juvenileidiopathicarthritis(JIA)...... 222 Juvenilerheumatoidarthritis(JRA) ...... 222 Juvenilescleromyositis...... 222 XII C

Kawasakisyndrome...... 222 Leukocytopenia...... 223 Leukocytosis ...... 223 Libman-Sacksendocarditis...... 224 Lilacrings...... 224 Livedoreticularis/racemosa...... 224 Lymphadenopathy...... 224 Lymphocytopenia ...... 225 Malabsorption ...... 225 Mechanic’shands...... 225 Membranousnephritis/nephropathy(MN)...... 225 Meningitis,aseptic...... 226 Mesentericinfarction...... 226 Microscopicpolyangiitis(MPA)...... 226 Microstomia...... 226 Migraine,atypical ...... 227 Mixedconnectivetissuedisease(MCTD)...... 227 Moschkowitz’ssyndrome ...... 229 Mucocutaneouslymphnodesyndrome...... 230 Muscleweakness...... 230 Muscularatrophy...... 230 Myalgia ...... 230 Myocardialinfarction...... 231 Myoglobin,elevatedinplasma ...... 231 Myositis,idiopathic...... 231 Myositisoverlapsyndromes...... 231 Neonatallupuserythematosus(NLE) ...... 231 Neonatallupussyndromes ...... 232 Nephritis ...... 232 Neuropathy...... 233 Organicbrainsyndrome...... 233 Otitisexterna...... 233 Otitismedia...... 233 Overlapsyndromes...... 234 Pancreaticinfarction...... 234 Pancreatitis ...... 234 Panniculitis ...... 234 Parotitis...... 234 Pericardial eﬀusion...... 234 Pericarditis ...... 235 Peritonitis...... 235 Photosensitivity...... 235 C XIII

Pleuritis...... 235 Polyarteritisnodosa ...... 236 Polymyalgiarheumatica(PMR) ...... 237 Polymyositis(PM)/Dermatomyositis(DM)...... 237 Polymyositis/sclerodermaoverlap ...... 239 Polyneuritis,cranial ...... 240 PrimarySjögren’ssyndrome...... 240 Proteinuria ...... 240 Pseudocaverns ...... 240 Psychosis ...... 240 Ptosis ...... 241 Pulmonary ﬁbrosis...... 241 Pulmonaryhemorrhage...... 241 Pulmonaryarterialhypertension(PAH)...... 241 Pulmonary inﬁltrates...... 242 Pulselessness ...... 242 Purpura...... 242 Raynaud’sphenomenon...... 242 Relapsingpolychondritis ...... 243 Retinitis...... 243 Retinalischemia ...... 244 Rheumatoidarthritis...... 244 Rheumatoidnodules...... 245 Rhinitis...... 246 Rhupus ...... 246 Saddlenose...... 246 Scleritis/Episcleritis...... 246 Sclerodactyly ...... 246 Scleroderma...... 246 Scleroderma/myositisoverlap...... 247 Sclerodermaspectrumdisorder ...... 247 Sclerosissinescleroderma...... 247 SecondarySjögren’ssyndrome ...... 248 Sensorineuralhearingloss...... 248 Sharpsyndrome ...... 248 Sinusveinthrombosis...... 248 Sinusitis...... 248 Sjögren’ssyndrome(SjS)...... 249 Sneddon’ssyndrome...... 252 Spinalinfarction ...... 252 Splenomegaly...... 252 Still’sdisease ...... 253 XIV C

Stroke ...... 253 Subacutecutaneouslupuserythematosus(SCLE) ...... 253 Systemiclupuserythematosus(SLE)...... 253 Systemicsclerosis(SSc) ...... 255 Systemicvasculitides...... 257 Takayasuarteritis...... 258 Teleangiectasia ...... 259 Temporalarteritis...... 259 Thrombocytopenia...... 259 Thrombocytopenicthromboticpurpura(TTP) ...... 260 Thrombocytosis ...... 260 Thrombosis...... 260 Thyroiditis ...... 260 Tolosa-Huntsyndrome ...... 260 Transitoryischemicattacks(TIA)...... 260 Transversemyelitis...... 261 Ulcers ...... 261 Undiﬀerentiatedconnectivetissuedisease(UCTD) ...... 261 Urticaria...... 262 Valvularheartdisease ...... 262 Vertigo...... 262 Wegener’sgranulomatosis(WG) ...... 263 Xerostomia ...... 264 Abbreviations...... 265 Appendices...... 267 Preface, 2nd edition

The determination of autoantibodies has become an integral part of the diagnosis and diﬀerential diagnosis, as well as the estimation of the prognosis and development of autoimmune diseases. Furthermore, because many disease-associated autoantibodies are detectable in preclinical stages, they have assumed a potential role in the very early diagnosis or risk assessment of disease development. The growing knowledge about the pathogenic and diagnostic value of autoantibodies in systemic diseases, and the discovery of novel autoantibodies and changes in classiﬁcation criteria necessitated the publishing of a revised and supplemented 2nd edition. Besides the clinically relevant autoantibodies also antibodies that may serve as tools in molecular, cell and tumor biological studies have been included. However due to the rapid development, the alphabetical catalogue of relevant or potential relevant autoantibodies is incomplete. Therefore, the authors appreciate helpful comments for future editions.

Karsten Conrad Marvin J. Fritzler Falk Hiepe Werner Schößler Preface, 1st edition

Among the challenges facing the new millennium physician are tremendous changes in biomedical and information technologies that are rapidly changing the nature and complexity of clinical practice. Since the discovery of the LE cell over 50 years ago, there has been a logarithmic increase in the description and clinical application of autoantibodies in an ever-widening spectrum of diseases. Systemic rheumatic diseases are among the most complex of these diseases because the clinical presentation and constellation of ﬁndings are in part reﬂected by the

spectrum of autoantibodies found in these conditions. The litany of autoantibody acronyms, designations and descriptors include Sm, dsDNA, SS-A/Ro,‘ SS-B/La, U1RNP, Jo-1, topo-I, CENP, Ku, Ki, Sa, and ribo P, to name a few. This antibody

alphabet soup’ has threatened to move clinical diagnostics into a literal Tower of Babel. ‘ It is important to appreciate how the antibody alphabet soup’ can be useful in the diagnosis and management of systemic rheumatic diseases. The applications are as varied and rich as are the multiplicity of the autoantibody speciﬁcities. Cer- tainly, autoantibody testing is not required to make a diagnosis in a woman who presents with a photosensitive skin rash, pericarditis, glomerulonephritis, anemia and psychosis. This patient clearly has SLE and the detection of autoantibodies conﬁrms the obvious.What may not be as clear is that the presence of anti-dsDNA could correlate with nephritis and the presence of anti-ribo P may indicate mani-

festations of central nervous system lupus in the presence of confounding factors “such as infections and drug use. In addition, not all patients present with classical textbook” features of systemic rheumatic diseases. Unfortunately, in many cases the time interval from the onset of symptoms to a confirmed diagnosis and meet- ing established criteria for the classification of disease,can be measured in decades. Thus, when there is limited (forme fruste) disease or a single disease manifestation, the detection of serum autoantibodies can play an important role in raising the suspicion of evolving disease and forecasting prognosis. A good example is the use of autoantibodies in the initial evaluation of Raynaud’s phenomenon. If the ANA and other autoantibody tests are negative, the likelihood that his patient has primaryRaynaud’sdiseaseislikelyandtheconcernthattheclinicalcoursewill transform into systemic rheumatic disease is lessened. On the other hand, ample  P,1  XVII clinical studies have shown that the presence of anti-topo-I (Scl-70) is a harbinger of diffuse scleroderma, antibodies to CENP are more predictive of the limited form of the disease, and the presence of anti-PM/Scl, indicates a scleroderma- polymyositis overlap syndrome. There many other examples of the clinical utility of autoantibody testing in isolated clinical scenarios such as polyarthritis, myosi-

tis, neuropathies, cytopenias, and vasculopathies that are characteristic, but not specific for, any single systemic‘ rheumatic disease. In many of these instances the presence of one or more alphabet soup’ antibodies can be a prologue to diseases thatarelikelytoevolveduringpatientfollow-up. While the diagnosis of forme fruste diseaseisanimportantuseofautoantibody testing,another valuable use is that they provide an understanding of the pathogen- esis. This has been clearly illustrated with the subsets of disease such as neonatal lupussyndrome,subacutecutaneouslupus,homozygousC2deficiency, interstitial lung disease, granulocytopenia, and Sjögren’s syndrome that are strongly associated with anti-SS-A/Ro. Compelling evidence shows that anti-SS-A/Ro binds with the cognate antigen in the fetal heart and in keratinocytes exposed to ultraviolet light. On the other hand, it is not clear how or if the same antibody participates in the development of keratoconjunctivitis sicca. The demonstration that riboso- mal P proteins and other autoantigens are found on the surface of some normal and apoptotic cells may provide an important clue to their potential pathogenic role. The notion that some autoantibodies may be fingerprints incriminating a causeoretiologyofthediseasearealsobeingclarified. For example, antibodies to fibrillarin (U3-RNP) are induced in certain strains of mice by heavy metal ex- posure and systemic sclerosis patients with these autoantibodies have high levels of urinary mercury. The future of autoantibody testing can be cast into at least four arenas. First, the rapid advancement of new technologies (autoantigen arrays, microfluidics and nanotechnology) will change the complexion of the autoantibody testing by pro- viding a wealth of serological information that will almost certainly challenge current paradigms and clinical associations. It is now possible to use a drop of blood to analyze serum for the presence of over 100 different autoantibodies in a single test that can be completed and reported within minutes. Second, it is antici- pated that autoantibody testing will be a critical part of monitoring and evaluating patients placed on a variety of the newer biological therapeutics. For example, it is increasingly clear that interferon and tumor necrosis factor blockade therapies are associated with the induction of autoantibodies and, in some cases, full blown disease.Interestingly,these observations fall on the historical evidence that drugs such as procainamide and hydralazine can induce autoantibodies and lupus syndromes. Third, it is likely that autoantibody testing will replace more invasive and costly diagnostic techniques such as the salivary gland biopsy for Sjögren’s syndrome, the small bowel biopsy for coeliac disease, the nerve and skin biopsy for vasculitis, the muscle biopsy for myositis, and many others. Fourth, carefully designed  XVIII P,1 

studies that assess the cost effectiveness of autoantibody testing are required. On one hand, there is the notion that in many patients, including the woman with unequivocal features of SLE described above, that even the relatively inexpensive autoantibody test is superfluous and not cost effective. However, the implications of longer term health care costs of missing an early diagnosis in a patient with forme fruste disease must also be carefully considered. A cost-effective and ratio- nal approach to autoantibody testing algorithms and clinical practice guidelines are overdue. Clinical studies to address these issues will prove worthwhile and save patients from needless, expensive and invasive tests, and missed diagnosis that can lead to significant morbidity and mortality. This book and reference guide is intended to assist the physician understand and interpret the variety of autoantibodies that are being used as diagnostic and prognostic tools for patients with systemic rheumatic diseases. Although the landscape of autoantibody testing continues to change,this information will be a useful and valuable reference for many years to come.

Marvin J. Fritzler Notes for the Use of this Book

This reference book on the serological diagnosis of systemic autoimmune diseases is divided into two main sections. The autoantibodies observed in autoimmune diseases are described in alphabetical order in Part 1, and autoimmune disorders as well as symptoms that indicate the possible presence of an autoimmune disease are listed in Part 2. Guide marks (the symbol “”) were inserted to ensure fast and easy cross-reference between symptoms, a given autoimmune disease and associated autoantibodies. Bibliographic references were omitted due to the broad

scope of the subject matter. Only the ﬁrst authors of historical or some important recent publications have been named. “

With some exceptions (e.g.,antinuclear antibodies) the preﬁx anti-”was omitted for better“ clarity of alphabetization. Anticentromere antibodies, for example, are listed as centromere antibodies”. In as far as they were known to the authors, synonyms or alternative names for the antibodies were also listed. Obsolete termi- nology is indicated as such, and the names preferred by the authors are used in the alphabetical index. The autoantibody description section begins, in some cases, with a brief in- troduction or historical account. This is followed by information on the target structures (autoantigens), detection methods, clinical relevance, and indications for testing of the autoantibody. The authors’ rating of the clinical relevance of each autoantibody listed in the book is indicated using variable coloring and lettering.

White Letters on Green Background

These are autoantibodies of high diagnostic relevance (markers for diagnosis, prognosis or monitoring) that can usually be determined in all laboratories. 2I

Black Letters on Medium Green Background

These are diagnostically relevant autoantibodies that are not measurable in all laboratories and therefore are determined in specialized laboratories only.

Black Letters on Light Green Background

The clinical relevance of these antibodies is (still) unclear due to their very low frequency of detection, discrepancies between the findings of different studies (lack of comparability due to differences in study design, methodology, ethnic differences, etc.), methodological problems, or preliminary nature of study findings.

Black Letters on White Background

These autoantibodies are currently not clinically relevant, are no longer clinically relevant, or are clinically relevant only in isolated cases. This can also include disease-speciﬁc autoantibodies if their testing does not provide any added diagnostic advantages over other parameters. Part 1 Autoantibodies in Systemic Autoimmune Diseases GWB A 75

GWB Antibodies

Synonym: Anti-GW bodies also referred to as mammalian processing (P) bodies.

Autoantigens

GWB autoantigens include a group of 3 GW proteins referred to as GW182, GW2 and GW3 as well as other components such as Ago2, Ge-1/Hedls and RAP55. They are localized to discrete cytoplasmic structures that are involved in mRNA processing. The GW antigens were so-named because they contain numerous glycine (G) and tryptophan (W) repeats and have a calculated molecular mass of 182 kDa) and they bind to mRNA as well as Ago2, and are key components of the RNA in- terference silencing complex (RISC) (reviewed in Jakymiw et al., 2007). The most common target antigen of GWB antibodies is Ge-1/Hedls followed by GW182 (Bhanji et al., 2007).

Detection Methods • IIF using monolayers of tissue culture or tumor cells, e.g., HEp-2 cells (Fig.12).

Figure 12. IIF pattern on HEp-2 cells (Immuno Concepts Ltd, Sacramento, USA) of an anti-GWB antibody positive serum: distinctive cytoplasmic dots varying in number from zeroinmitoticcells(1)tomorethan30ininterphasecells(2). 76 A  S A D

N: The frequency of detection of anti-GWB depends on the cell line and tissue that is used for the assay because GWB are most highly expressed in rapidly proliferating cells and in testis and a subset of neural cells. In addition, anti-GWB may be obscured by high titer anti-cytoplasmic antigens such as anti-mitochondrial antibodies. • IIF using monoclonal anti-GW182 for co-localization • IB using whole cell extracts or puriﬁed GWB fractions. • EIA or ALBIA using recombinant GW,Ago2, Ge-1/Hedls and RAP55 proteins. • IP of recombinant protein produced by in vitro transcription and translation of cDNA of respective antigens.

Clinical Relevance • Moderate to high titers of anti-GWB are found in ∼ 0.4 % of routine screening using HEp-2 cells (Stinton et al., 2004). They are primarily associated with Sjögren’s syndrome, ataxia and other neuropathies, systemic lupus erythematosus (SLE), primary biliary cirrhosis (Bloch et al., 2005) and also found in other systemic autoimmune rheumatic diseases. • A systematic study of cohorts of various autoimmune diseases is needed now that rapid and sensitive array technology (e.g. ALBIA) is available. • It is important to note that the detection of anti-GWB may be masked by other autoantibodies (i.e. antimitochondrial antibodies in primary biliary cirrhosis) or overlooked in the presence of strong ANA.

Indications

None currently established. Comments: If the typical cytoplasmic discrete speckled pattern is found during screening with HEp-2 cells, serological follow-up to rule out reactivity with other cytoplasmic antigens that give a similar pattern (i.e. EEA-1, lysosome) is required. This can be partly accomplished by co-localization studies. However, it should be noted that GWB are quite heterogeneous with respect to content of any one of the components. Thus, analyses of autoantibodies with multiplexed array technologies are preferred once the distinctive staining pattern is identiﬁed. At the clinical interface, examinations should be performed, e.g., to detect the potential development of connective tissue disease (Sjögren’s syndrome) and neurological conditions such as ataxia and sensory/motor neuropathies. Cooperation with a research laboratory can be useful, e.g., for determination of the speciﬁcity and further evaluation of the potential clinical relevance of these antibodies.  H-RNA (RNAH )S (HRS) A 77

Heat Shock Protein (Hsp) Antibodies

Collective term for all autoantibodies directed against heat shock proteins/heat stress proteins (Hsp).

Autoantigens

Various heat shock proteins (heat-stress-induced proteins) like Hsp60, Hsp70 and Hsp90.

Detection Methods • WB using cell extracts after one- or two-dimensional separation. • EIAusingbiochemicallypuriﬁed or recombinant heat shock proteins.

Clinical Relevance

Hsp antibodies occur in a number of autoimmune and non-autoimmune diseases (especially infections) as well as in healthy individuals.

Indications

None related to systemic autoimmune diseases. The use of Hsp antibodies for diagnosis of arteriosclerosis and autoimmune diseases of the inner ear is being evaluated.

Histidyl-tRNA (tRNAHis) Synthetase (HRS) Antibodies

See Jo-1 antibodies, Aminoacyl-tRNA synthetase antibodies.

Histone Antibodies

Synonym: Anti-histone antibodies (AHA). 78 A  S A D

History: Histone antibodies appear to be involved in the LE cell phenomenon that was ﬁrst described in1948.H2A-H2B antibodies and, more recently,H1antibodies have been implicated in this phenomenon, which was an important milestone in the discovery of autoantibodies associated with SLE ( LE cell factor).

Autoantigens

Histones can be found in almost all eukaryotic cell nuclei. The histone family contains the following ﬁve basic proteins: H1 (26.5 kDa), H2A (14 kDa), H2B (13.8 kDa), H3 (15.3 kDa) and H4 (10.2 kDa). Histones form complexes with double-stranded DNA, called nucleosomes. The DNA thereby wraps around dimeric H2A-H2B and H3-H4, while H1 binds to DNA on the surface of the nucleosome. The bead-like nucleosomes help bundle the DNA into a more compact chromatin structure. All histones and histone complexes can be targeted by autoantibodies.

Detection Methods • IIF using HEp-2 cells: Chromatin can be visualized like the pattern produced by dsDNA antibodies (homogeneous staining of interphase nuclei and of the chromatinregioninmitoticcells). N: Anegativeimmunoﬂuorescence does not exclude the presence of AHA. • EIA, ALBIA and LIA using isolated histones or histone mixtures. • RIA using isolated histones or histone mixtures. • WB.

Comments: The conformational epitopes may be altered or destroyed due to solid phase binding (EIA) and/or the use of SDS-polyacrylamide gel electrophoresis (WB).

Clinical Relevance • With the possible exception of anti-H1,AHA are not speciﬁcforanyonedisease, but can be detected in a number of autoimmune diseases, especially rheumatic disorders: Systemic lupus erythematosus (SLE; 50–80 %), drug-induced lupus (DIL; 92–95 %), rheumatoid arthritis (RA; up to 11%), RA vasculitis (up to 75 %), Felty’s syndrome (up to 79 %), juvenile idiopathic arthritis (JIA; up to 51%), systemic sclerosis (SSc; up to 30 %),ANA positive undiﬀeren- tiated connective tissue diseases (up to 90 %), primary biliary cirrhosis (up to 55 %), autoimmune hepatitis (up to 35 %). Furthermore,AHA are detectable in patients with neoplastic diseases,subacute sensoric neuropathies and infections. HMG A 79

• High titers of AHA are found almost exclusively in patients with SLE and DIL. The detection of high AHA titers in the absence of SLE marker antibodies is characteristic of drug-induced lupus. • AHAcanbeoftheIgG,IgMorIgAisotype.IgGAHAappeartoberelatedto the disease activity of lupus. • In patients with SSc, AHA are associated with lung, heart and kidney involvement (Hesselstrand et al., 2003). A strong correlation of AHA with the number of morphea lesions and the number of involved areas of the body have been described in patients with localized sclerodema (Takehara et al., 2005).

Indications 1. Suspicion of drug-induced lupus (especially after procainamide, hydralazine, isoniazid, chlorpromazine, methyldopa, beta blockers, anticonvulsant, sul- fasalazine or captopril use). N: To establish the diagnosis of drug-induced lupus, the potential presence ofSLEmarkerantibodies(i.e., dsDNA and Sm antibodies) must be ruled out using the appropriate tests.Antihistone antibodies tend to disappear within one year of discontinuing the causative drug. 2. Diﬀerential recognition of antinuclear antibodies in sera presenting a typical chromatin ﬂuorescence pattern.

HMG Antibodies

Autoantigens

Chromosomal high mobility group (HMG) proteins. The proteins HMG-1, -2, -14 and -17 have been described as target proteins of autoantibodies involved in systemic autoimmune diseases. Furthermore, antigens with HMG motifs (HMG-box proteins such as Sp100, SOX13) can be targeted by antibodies from autoimmune patients (Fida etal., 2002).

Detection Methods • WB using cell extracts or HMG preparations. • EIAusingbiochemicallypuriﬁed HMG. Part 2

Systemic Autoimmune Diseases – Syndromes, Diagnostic Criteria, Symptoms 192 S A D  S,D,S

Abortion, spontaneous

Recurrent spontaneous abortions that generally occur after the 10th week of gestation (caused by thrombotic events in the placenta) are a characteristic sign of antiphospholipid syndrome.

Acidosis, renal-tubular

Renal manifestation of Sjögren’s syndrome.

Acro-Osteolysis

Occurs as a typical feature of systemic sclerosis and is a reﬂection of a severe acral microcirculatory disorder.

Addison’s disease

May be due to thrombosis of the blood vessels of the adrenal glands as a rare complication (<1%) of antiphospholipid syndrome.

Adrenocortical failure

Addison’s disease

Aldolase, elevated in plasma

Polymyositis/dermatomyositis Mixed connective tissue disease (MCTD) A 193

Alopecia

Diﬀuse (alopecia diﬀusa) or localized alopecia (alopecia areata) may occur in cuta- neous lupus erythematosus (ANA negative!) or systemic lupus erythematosus.

Alveolitis

Interstitial lung involvement occurs in:

Systemic lupus erythematosus, Sjögren’s syndrome, Polymyositis/dermatomyositis, Systemic sclerosis, Scleroderma/myositis overlap syndrome, Microscopic polyangiitis (hemorrhagic alveolitis is a feared complication!).

Typical feature of: Anti-Jo-1 syndrome or anti-synthetase syndrome. See also hemorrhagic alveolitis.

Amaurosis fugax

Reversible, mostly unilateral blindness due to retinal circulatory disorder. Rare ophthalmologic manifestation of antiphospholipid syndrome (in 5 %). Also symptom of giant cell arteritis (temporal arteritis).

ANCA-associated vasculitis

Group of primary systemic vasculitides associated withANCA ( cANCA/proteinase 3antibodies, pANCA/myeloperoxidase antibodies):

Wegener’sgranulomatosis(WG), Microscopic polyangiitis (MPA), Churg-Strauss syndrome (CSS). 194 S A D  S,D,S

Anemia

Anemia may occur in all inﬂammatory diseases and is associated with the degree of inﬂammatory activity. Coombs-positive autoimmune hemolytic anemia may occur in systemic lupus erythematosus and rarely in other connective tissue diseases. Coombs-positive hemolytic anemia occurs in about 9 % of patients with antiphospholipid syndrome.

Anti-Jo-1 syndrome

Original name for anti-synthetase syndrome.

Antiphospholipid syndrome (APS)

Synonyms: Hughes syndrome, anticardiolipin syndrome, phospholipid antibody syndrome, cardiolipin antibody syndrome APS is one of the most common autoimmune diseases. Its clinical picture is ex- tremely variable, and the complications arising from the disease may be minimal to life-threatening. The features of APS include venous and arterial thrombosis, recurrent spontaneous abortions, neurological complications and phospholipid antibody expression. APS may occur as an isolated disease entity (formerly primary antiphospholipid syndrome) or in combination with another autoimmune disease, especially systemic lupus erythematosus (formerly secondary antiphospholipid syndrome). Sneddon’s syndrome and Budd-Chiari syndrome are partially attributable to APS. The catastrophic antiphospholipid syndrome is a rare form of APS characterized by extensive vascular occlusions in multiple organ systems, leading to renal failure and malignant arterial hypertension, severe CNS manifestations, acrocyanosis and gangrene. A workshop, preceding the Eleventh International Congress on antiphospholipid antibodies (aPL) in Sydney, Australia, considered revisions to the international classiﬁcation criteria for APS. A  (APS) 195

Revised classiﬁcation criteria for the APS [according to M et al., 2006]

Clinical criteria 1. Vascular thrombosis* Oneormoreclinicalepisodesofarterial,venous,orsmallvesselthrom- bosis. Thrombosis must be confirmed by objective validated criteria (i.e.unequivocal findings of appropriate imaging studies or histopathol- ogy). For histopathologic confirmation, thrombosis should be present without significant evidence of inflammation in the vessel wall. 2. Pregnancy morbidity a) One or more unexplained deaths of a morphologically normal fetusatorbeyondthe10th week of gestation, with normal fetal mor- phologydocumentedbyultrasoundorbydirectexaminationofthe fetus, or b) One or more premature births of a morphologically normal neonate before the 34th week of gestation because of (i) eclampsia or severe preeclampsia defined according to standard definitions, or (ii) recognized features of placental insufficiency, or c) Three or more unexplained consecutive spontaneous abortions before the 10th week of gestation, with maternal anatomic or hormonal abnormalities and paternal and maternal chromosomal causes excluded. In studies of populations of patients who have more than one type of pregnancy morbidity, investigators are strongly encouraged to stratify groups of subjects according to a, b, or c above.

Laboratory criteria** 1. Lupus anticoagulant (LA) present in plasma, on two or more occasions at least 12 weeks apart, detected according to the guidelines of the International Society on Thrombosis and Haemostasis (Scientiﬁc Subcommittee on LAs/phospholipid-dependent antibodies) (Brandt et al., 1995, Wisloﬀ et al., 2002). See Lupus anticoagulant. 2. Anticardiolipin (aCL) antibody of IgG and/or IgM isotype in serum or plasma, present in medium or high titer (i.e. > 40 GPL or MPL, or > the 99th percentile), on two or more occasions, at least l2 weeks apart, measured by a standardized EIA (Tincani et al.,2001; Harris et al.,2002; Wong et al., 2004). See Cardiolipin antibodies. 196 S A D  S,D,S

3. Anti-β 2 glycoprotein I antibody of IgG and/or IgM isotype in serum or plasma (in titer > the 99th percentile), present on two or more occasions, at least 12 weeks apart, measured by a standardized EIA, according to recommended procedures (Reber et al., 2004). See β2 glycoprotein I antibodies. Deﬁnite APS is considered to be present if at least one of the clinical criteria and one of the laboratory criteria are met.

It must be pointed out that the classiﬁcationofAPSshouldbeavoided if less than 12 weeks or more than 5 years separate the positive aPL test and the clinical manifestation.

∗ Coexistinginheritedoracquiredfactorsforthrombosisarenotreasonsforex- cluding patients fromAPS trials.However,two subgroups of APS patients should be recognized, according to: (a) the presence, and (b) the absence of additional risk factors for thrombosis. Indicative (but not exhaustive) such cases include: age (> 55 in men,and > 65 in women),and the presence of any of the established risk factors for cardiovascular disease (hypertension, diabetes mellitus, elevated LDL or low HDL cholesterol, cigarette smoking, family history of premature cardiovascular disease,body mass index ≥ 30 kg m–2, microalbuminuria,estimated CFR < 60 m min–1), inherited thrombophilias, oral contraceptives, nephrotic syndrome, malignancy, immobilization, and surgery. Thus, patients who fulﬁl criteria should be stratiﬁed according to contributing causes of thrombosis. ∗∗ Investigators are strongly advised to classify APS patients in studies into one of the following categories: I, more than one laboratory criteria present (any combination); IIa, LA present alone; IIb, aCL antibody present alone; IIc, anti-β 2 glycoprotein I antibody present alone. Features associated with APS but not included in the revised criteria:

• heart valve disease (Libman-Sacks endocarditis; rheumatic fever and septic endocarditis have to be excluded) • livedo reticularis • thrombocytopenia • nephropathy • neurological manifestations (cognitive dysfunction, transient cerebral ischemia and stroke, dementia, transverse myelopathy, seizure) • IgA aCL • IgA anti-β 2GPI • antibodies against phosphatidylserine • antibodies against phosphatidylethanolamine A-SRP  197

• antibodies against prothrombin alone • antibodies to the phophatidylserine-prothrombin complex

Autoantibodies: Phospholipid antibodies (see also appendix VI)

Anti-SRP syndrome

A subtype of idiopathic myositis (see Polymyositis). Characteristic features:

• Predominantly occurs in women of black African descent • Acute/subacute onset with severe polymyositis • Cardiac involvement frequently occurs • Severe myonecrosis with only minimal inﬂammation • Responds poorly to immunosuppressive therapy; very poor prognosis (5-year mortality of 75 %!)

Comment: In rare cases atypical clinical manifestations may occur in the presence of necrotizing myopathy (Dimitri et al., 2007). Autoantibodies: SRP antibodies serve as diagnostic marker. Ro52 antibodies can be found but did not have any diagnostic or prognostic relevance.

Anti-Synthetase syndrome

Synonym: Anti-Jo-1 syndrome. Subtype of idiopathic myositis (see Polymyositis) characterized by the additional occurrence of arthralgia/arthritis and interstitial lung involvement (alveolitis, pulmonary ﬁbrosis) and the detection of autoantibodies that react with tRNA synthetases (especially Jo-1).

Major criteria of the anti-synthetase syndrome

1. Polymyositis 2. Polysynovitis (arthralgia, arthritis, tenosynovitis) 198 S A D  S,D,S

3. Interstitial lung disease (ﬁbrosing alveolitis) 4. Aminoacyl-tRNA synthetase antibodies

Additional associations

• Rhagades and keratoses of the hands (“mechanic’s hands”) • Raynaud’s phenomenon • Acrosclerosis • Sicca symptoms • Dermatomyositis-like skin manifestations

Autoantibodies: Aminoacyl-tRNA synthetase antibodies are diagnostic markers. Among these, Jo-1 antibody is the most common detectable biomarker. Ro52 antibodies are found at high frequencies but without aid in diagnosing this type of autoimmune myositis.

Arthralgia

Common feature of all degenerative and inflammatory rheumatic diseases; frequently occurs as a manifestation of systemic and organ-specificautoimmune diseases. Autoantibodies: Patients suspicious for inflammatory rheumatic disease should be screened for antinuclear antibodies (ANA), antineutrophil cytoplasmic antibodies (ANCA), CCP/citrullinated protein/peptide antibodies and rheumatoid factor (RF).

Arthritis

Characteristic feature of inﬂammatory joint diseases: HLA-B27 associated spondylarthropathia, juvenile chronic arthritis (JIA), rheumatoid arthritis (RA). Common symptom of systemic autoimmune diseases: Connective tissue diseases, systemic vasculitides, relapsing polychondritis, hypocomple- mentemic urticarial vasculitis syndrome. Autoantibodies: Patients suspicious for inﬂammatory rheumatic diseases should be screened for antinuclear antibodies (ANA), antineutrophil cytoplasmic