Case Nº4 - FJM

A 68-year-old woman was admitted to our hospital with
general fatigue, palpitation, shortness of breath and leg
edema. She was diagnosed as having rheumatoid arthritis
(RA) at age 59 years at another hospital. She had since been
treated with nonsteroidal anti-inflammatory drugs, gold sodium
thiomalate and steroids. When she consulted our hospital,
clinical classification was stage IV and class II, due to
the bilateral erosive arthritis in her hands, wrists, knees and
feet.

In 1996 (at age 62 years), pancytopenia, which might
have been induced by gold sodium thiomalate, gradually developed.
This medication was discontinued, but the pancytopenia
persisted. Over the subsequent year, findings on gastrointestinal
endoscopy and abdominal computed tomography
revealed contracted liver, splenomegaly and esophageal
varices. Laboratory data showed no antigens or
antibodies for hepatitis virus, or antibodies for mitochondria
or smooth muscle, with the exception of antinuclear antibody
(ANA). Esophageal variceal banding ligature was thus performed.
Physical examination demonstrated deformities of the bilateral
joint of the hands, wrists, and feet. Swan-neck, boutonniere
deformity and radial deviation at the wrists with
ulnar deviation of the digits were noted in both hands.
Respiratory and heart sounds were normal. The spleen was
palpable about 5 cm below the left costal margin. Slight pitting
edema was observed in the bilateral lower extremities.

Laboratory findings are shown in Table 1. Urinalysis was
within the normal range. Neutropenia and hypoproteinemia
worsened, and hypoalbuminemia at 2.0 g/dl was detected.
Elevated levels of total bilirubin and aspartate aminotransferase
were observed, and the Child-Pugh classification was C (10 points).
ANA was positive at a titer of 640 (homogenous
and speckled), but other antibodies were negative.
Abdominal computed tomography revealed contracted liver,
splenomegaly, ascites and enlarged serpiginous
splenic vein.






























During admission, oral prednisolone was discontinued
due to various infections, including bacterial pneumonia and
methicillin resistant Staphylococcus aureus (MRSA) colitis.
Subcutaneous administration of granulocyte colony stimulating
factor (three times a week) was thus performed, while
ascites was simultaneously treated with diuretics. Laparoscopic
liver biopsy was not performed due to marked ascites
and neutropenia. Liver dysfunction worsened gradually and
ascites became prominent. She developed
hepatic encephalopathy and died from hepatic failure
and emaciation on March 31, 2003. Autopsy was not permitted.

¿What is the diagnosis?

Needle autopsy of the liver confirmed chronic hepatitis, the lobular architectures were maintained, while part of the portal field exhibited fibrosis including piecemeal necrosis, and was invaded by inflammatory cells and numerous lymphocytes with plasma cells (Fig. 3A, 3B). Pathological findings were consistent with a diagnosis of chronic hepatitis, which appeared to be AIH, although inflammatory cell invasion was not severe. According to the criteria of the International Autoimmune Hepatitis Group (Table 3A, 3B), the patient scored 19 points based on laboratory findings, pathophysiological consequences and clinical course, and her condition was diagnosed as AIH.

Discussion
In 1924, Felty first called attention to five cases with a
triad of RA, splenomegaly and neutropenia (5). This combination
of disorders was designated Felty’s syndrome in a
subsequent report by Hanrahan and Miller (6). This syndrome
frequently induces extra-articular features including
liver involvement, while common hepatic abnormalities are
nodular regenerative hyperplasia, abnormal lobular architecture,
portal fibrosis and cirrhosis (7–11). Thorne et al reported
a tendency for patients with abnormal liver findings to
have a higher incidence of vasculopathy and Felty’s syndrome
patients should be screened for portal hypertension as
they have an increased likelihood of bleeding from esophageal
varices (9). Indeed, in this patient, esophageal varices
were observed. The most common liver involvement in patients
with Felty’s syndrome is nodular regenerative
hyperplasia (12, 13). Goritsas et al recommended that signs
of portal hypertension and/or intrahepatic cholestasis in RA
patients should alert the physician to the possibility of nodular
regenerative hyperplasia, even in the absence of Felty’s
syndrome (14). However, the cause of hepatic nodular regenerative
hyperplasia in patients with Felty’s syndrome remains
unresolved.
In the present case, contracted liver was thought to be
clinically liver cirrhosis based on blood test, abdominal computed
tomography and ultrasonography findings. However,
liver autopsy findings revealed chronic hepatitis. Histological
findings showed a basically normal architecture and
338 Internal
a partly piecemeal necrosis in the portal triad field, in addition
to infiltration of lymphocytes with plasma cells, which
suggested AIH.
AIH was first reported by Mackay et al in 1965. The characteristic
pathologic features were chronic active hepatitis
with piecemeal necrosis, lobular involvement, and bridging
necrosis with lymphocytes and plasma cells (15). The clinical
features were similar to chronic viral hepatitis. For diagnosis
of AIH, it was recently recommended to use the
scoring system of the International Autoimmune Hepatitis
Group (16). According this scoring system, the present patient
was diagnosed as having autoimmune hepatitis with a
score 19 points. Kaise et al reported that one in 49 patients
with Felty’s syndrome exhibits concomitant AIH (11). Based
on that report, it is certain that AIH in Felty’s syndrome is
extremely rare.

Minimum Required Parameter



















Aditional Parameters



















Splenomegaly in patients with Felty’s syndrome might be
due to expansion of the sinusoidal pulp, as indicated by
wider separation of the periarterial lymphoid sheaths and
hyperplastic germinal center (17). In the present case, we are
convinced that increasing blood flow to the spleen due to
splenomegaly caused portal hypertension, congestion of
blood within the liver, and chronic hepatitis gradually worsened
to liver failure.
The present patient had contracted liver disease of unknown etiology. Chronic hepatitis compatible with AIH was
diagnosed based on an international scoring system and the
pathological findings of needle autopsy respectively. In patients
with Felty’s syndrome, severe hepatitis is rarely observed
and correlations with the liver are difficult to confirm.
When treating Felty’s syndrome patients with severe liver
dysfunction, AIH should be considered. Inaba et al reported
a case in which the patient had been treated by prednisolone
for AIH and was diagnosed as having Felty’s syndrome (18).
This report raises the possibility that our patient had AIH when she was diagnosed with RA and prednisolone therapy suppressed the clinical features of AIH. Retracing the clinical course, liver dysfunction may have developed after steroid therapy was discontinued. If this was the case scenario, the response to therapy in this patient should, in fact, be considered as a relapse with a score of 21 points. In the present
patient, the most difficult point was that steroid therapy had
to be discontinued due to life threatening infections (MRSA
colitis, recurrent pneumonia) which might have been due to
neutropenia and steroid therapy. Interruption of steroid therapy
in this patient may have been a crucial event in the ultimate
clinical course.

Reference

- Felty’s Syndrome with Chronic Hepatitis and
Compatible Autoimmune Hepatitis: A Case Presentation

Antinuclear Antibodies in rheumatology - A Mod Rheumatology Review

Clues

• The antinuclear antibodies of 1:160 are very specific for collagen diseases, with less than 5% yield positive result in healthy population
• There are stains and patterns of antibodies; stains: nuclear, nucleolar, cytoplasmic, mitotic, golgi bodies stains; and the patterns varies according to the staining (e.g. in the nuclear staining, are three types of patterns: homogeneus, peryphery and speckled)
• The more specific Antibodies for SLE are: ANA with nuclear staining with homogeneus, speckled and peripheral pattern, Anti-dsDNA and Anti-Sm
• The more specific Antibodies for Scleroderma are: ANA with nucleolar staining, Anti-topoI, Anti-RNAPIII and Anti-centromere.
• The more specific Antibodies for Dermatomiositis-Polymiositis are: ANA with cytoplasmic staining, Anti-Jo1.
• The more specific Antibodies for Sjogren Disease are: ANA with nuclear staining in a speckled pattern and Anti-Ro/SS and Anti La-SS

The incubation of human sera with fixed cells is followed by fluorochrome (such as

fluorescein isothiocyanate: FITC) conjugated antibodies against human IgG. Observing under

a fluorescent microscope allows one to determine the patterns as well as titers of autoantibodies.

This standard method of performing antinuclear antibody (ANA) tests by immunofluorescence

has been used for over 40 years as a first-step screening test for autoimmune diseases and is

still the standard method. Although the ANA test has a nearly 100% sensitivity for the diagnosis

of SLE, it is not specific for this diagnosis and is frequently positive in other systemic

autoimmune rheumatic diseases such as SSc, PM/DM, and SjS as well. ANA is also found in

organ-specific autoimmune diseases, and in other nonautoimmune diseases such as viral

infections [

Although it is usually called the ANA test, the same procedure also exhibits reactivity against

all types of subcellular structures and cell organelles including cell surfaces, cytoplasm, nuclei,

or nucleoli [1]. The antigens recognized are mainly proteins, protein macromolecular

complexes, protein–nucleic acid complexes, and nucleic acids. In fact, most autoantibodies

that are clinically useful target RNA–protein or DNA–protein complexes. The staining may

be purely nucleolar, as seen in certain SSc patients, or purely cytoplasmic, as in anti-Jo-1

positive PM/DM patients. Thus, the ANA test is not just for “nuclear” staining.

The interpretation of most nuclear staining patterns is relatively straightforward, and they are

usually reported as being nuclear, centromere, or nucleolar. Cytoplasmic staining may not be

reported at all by some laboratories, and it is useful to know and distinguish whether it was

read as negative or it was simply not reported by the technical staff at the laboratory. A positive

nuclear staining result will usually come back with a more detailed staining pattern, such as

speckled (Fig. 1a), homogeneous, or peripheral. A homogeneous/peripheral pattern reflects

antibodies to histone/dsDNA/chromatin, whereas many other specificities found in systemic

rheumatic diseases show speckled patterns of various sizes and densities (fine speckled, large

speckled, etc.). Thus, while this information is somewhat useful, it is relatively subjective, and

varies depending on the laboratory or individual; the pattern may also differ at different

dilutions. A centromere pattern is usually reported as distinct pattern, but they can also be

termed discrete speckled nuclear staining patterns (Fig. 1b). Unusual staining patterns in nuclei,

such as those for the nuclear mitotic apparatus (NuMA) [3] (Fig. 1c), Cajal body (p80-coilin),

or nuclear dots (Fig. 1d), may not be reported depending on the experience of the laboratory.

The cytoplasmic staining shown by anti-Jo-1 (histidyl tRNA synthetase) antibodies in PM/DM

or antimitochondrial antibodies in primary biliary cirrhosis (PBC) (Fig. 1d) is often either not

reported or incorrectly interpreted. The staining from cytoplasmic dots called GW bodies

(GWBs)/P-bodies (Fig. 1e) was ignored or unrecognized until recently [4], but this cytoplasmic

structure has become a hot area of research in molecular and cellular biology following the

discovery of the critical role it plays in the functions of siRNA and miRNA [5,6]. Furthermore,

anti-Su antibodies that recognize a component of GWB, Ago2 [7], are very common

autoantibodies found in 10–20% of various systemic autoimmune diseases in American and Japanese populations [8] and ~25% of Mexican SLE patients (Vázquez-Del Mercado,

manuscript in preparation). Thus, GWB staining from anti-Su antibodies is in fact a quite

common staining pattern if it is recognized by an experienced laboratory [1]. Golgi patterns

[9] may also be overlooked or not reported properly in routine screening tests [1]. Another

example of unrecognized staining is a complete lack of reports of punctate nucleolar staining

by anti-RNA polymerase I from hospital laboratories

The introduction of human cancer cell lines (human laryngeal cancer cell line HEp-2 is the

standard) as a substrate for the ANA test significantly increased the sensitivity in the detection

of ANA in patients with systemic rheumatic diseases. However, a concomitant increase in

positive results in healthy individuals decreased the specificity. One multicenter study reported

that 31.7% of normal individuals were ANA positive at 1:40 dilution, which was decreased to

13.3% at 1:80 and 5.0% at 1:160 dilution. Since ~95% of SLE were still positive at 1:160

dilution, raising the negative cut-off titer from 1:40 to 1:160 may improve the distinction

between a clinically significant ANA result and a positive ANA result occurring in a normal

individual [2]. The frequency of positive ANA detection using this cut-off was 95% in SLE,

87% in SSc, 74% in SjS, and 14% in RA

There is some

evidence that clinical manifestations associated with certain autoantibodies are more evident

among patients with high titers of that specificity. Sclerodactyly, Raynaud’s phenomenon and

vascular disease associated with anticentromere antibodies are more common in patients with

high titers of this specificity than in those with low titers [11]. Classic feature of mixed

connective tissue disease (MCTD) is associated with very high titers of anti-U1RNP antibodies

[12,13]. However, it should be noted that higher titers of ANA do not always mean that the

patient’s disease is more severe or active. Specificity of autoantibodies is one of the factors

that correlate strongly with titers of ANA. Certain autoantibodies such as anti-dsDNA usually

show relatively low titers in ANA, while others such as anti-U1RNP and centromere may show

titers of 1:10,240 or even higher [11]. Individuals with high titers of these antibodies may lack

serious organ involvement, being classified as having undifferentiated connective tissue

disease (UCTD) or Raynaud’s disease, and may not require any medical treatment [14,15]. On

the other hand, patients with low titers of disease marker antibodies (see the next section) could

have a typical disease requiring attention and follow-up.

Anti-Sm and anti-dsDNA antibodies are highly specific for the

diagnosis of SLE and are included in the classification criteria for SLE by the American College

of Rheumatology (ACR) [16]. ANA is also included among these criteria, and nearly all SLE

patients are ANA positive; however, ANA is not specific for SLE. Antiphospholipid

antibodies, listed under immunological disorders in the SLE criteria, are also common in SLE

but can also be found in various systemic rheumatic diseases and often in patients with antiphospholipid

syndrome who do not fulfill the criteria for any rheumatic diseases.

Antiribosomal P antibodies found in ~10% of patients and anti-PCNA (proliferating cell

nuclear antigen) antibodies seen in ~2% of SLE patients are also considered to be diseasespecific,

but the supporting data are not as extensive as those for anti-dsDNA or anti-Sm [1,

17,18]. An association between anti-ribosomal P antibodies and neuropsychiatric symptoms

has been suggested for many years, but a recent meta-analysis indicated that anti-ribosomal P

antibody testing has a negligible capacity to predict neuropsychiatric manifestations of SLE in

individual cases

Antitopoisomerase I (topo I, Scl-70), found in 15–25% of patients, and anti-RNA polymerase

III (RNAP III) antibodies, found in 20–25% of patients, are highly specific for SSc [20–23].

Anticentromere antibodies were classically described in association with a subset of SSc,

CREST syndrome (calcinosis, Raynaud’s phenomenon, esophageal dysmotility, sclerodactyly,

and telangiectasias) [24]; however, this specificity is also common in limited SSc without

typical features of CREST syndrome. It can also be found in other diagnoses [25,26] and in

UCTD [11,14]. Anti-U3RNP (fibrillarin) and anti-Th are also considered SSc markers,

although they may also be found in idiopathic interstitial lung disease (ILD) or primary

pulmonary hypertension without apparent SSc at low frequency [27,28]. Antitopo I, RNAP

III, and U3RNP are associated with diffuse SSc, whereas anticentromere and Th are mainly

found in limited SSc. Severe ILD is frequently found in antitopo I positive patients, while it is

rare in anti-RNAP III positive cases. Anti-RNAP III is strongly associated with scleroderma

renal crisis. Isolated pulmonary hypertension is more common in patients with anticentromere,

U3RNP, and Th. Other SSc-related autoantibodies are also associated with unique clinical

Features.

In PM/DM, the anti-Jo-1 antibodies found in ~20% of patients are classic disease marker

antibodies, and are associated with a unique subset of PM/DM called anti-synthetase syndrome,

characterized by symptoms such as myositis, ILD, arthritis, Raynaud’s phenomenon, and

mechanic’s hand. Autoantibodies to other aminoacyl tRNA synthetases including PL-7

(threonyl), PL-12 (alanyl), EJ (glycyl), OJ (isoleucyl), and KS (asparaginyl) are also associated

with similar clinical features [32,33]. Although either myositis or ILD can precede the other

symptoms [34], anti-PL-12 and anti-KS may be more frequent than the others in idiopathic

ILD without myositis [35]. Antibodies to SRP (signal recognition particle) are also specific

for PM and are associated with severe myositis that occurs without histopathological

inflammation and is resistant to treatment [36]; however, the unavailability of an anti-SRP test

limits its clinical utility.

Other types of autoantibodies are found in various systemic rheumatic diseases, but they are

associated with certain clinical symptoms, regardless of the diagnosis [1]. Autoantibodies in

this category include anti-Ro/SS-A and La/SS-B (associated with SjS), anti-U1RNP

(associated with Raynaud’s phenomenon, swollen hands, leukopenia, overlapping features

such as sclerodactyly or myositis) [12], and anti-Ku (associated with muscle involvement)

In SLE, three autoantibody tests—anti-Sm, dsDNA, and phospholipid—included in the

classification criteria of SLE are commercially available in addition to standard

immunofluorescent ANA. Anti-dsDNA antibodies are detected at some point during the course

in ~70% of patients. Anti-Sm is found in ~15% of patients. Antiribosomal P, available as Ppeptide

ELISA, is found in ~10% of patients (Table 1).

Among SSc-associated autoantibodies, only tests for anti-topo I (found in 15–25%, Fig. 2 left),

anticentromere (20–25% by ANA), and anti-U1RNP (10%, frequency depends on whether

MCTD is classified as a separate entity) were available until recently. Anti-RNAP III antibodies

seen in ~20% of SSc patients have been described for 20 years [20–22]. However, anti-RNAP

III has not become standard or received as much clinical appreciation as that anti-topo I despite

its high specificity for SSc and tight link to scleroderma renal crisis [23,30,31]. This is mainly

because anti-RNAP III can only be detected by immunoprecipitation, which has been

performed at only a small number of institutes around the world. However, an anti-RNAP III

ELISA kit [40] was approved by the Food and Drug Administration (FDA)

In PM/DM, anti-Jo-1, found in ~20% of patients, is the only commercially available test for

myositis-specific antibodies

Although these new assays can be cost efficient and are somewhat comparable to

immunofluorescent ANA, to avoid confusion during interpretation by the clinician, laboratory

results derived from these assays should be reported along with exactly the type of assay used;

it should not be reported as an “ANA screening test.” Immunofluorescence ANA is still the

gold standard for the screening of ANA

For example, if strong nucleolar staining accompanies weaker nuclear

staining, as in certain anti-topo I-positive sera, it may be reported as nucleolar staining only.

Similarly, weak nuclear staining may be reported as negative in the presence of strong

cytoplasmic staining. Second, the report on the staining pattern may not always accurately

reflect the known cell biological location of the target antigen. Ro/SS-A antigens are present

in both nuclei and cytoplasm; however, anti-Ro/SS-A has been historically linked with ANAnegative

lupus, and the staining pattern from anti-Ro/SS-A has been controversial; nuclear

staining are reported by many, while some have reported cytoplasmic staining.

SLE: If SLE is clinically suspected, three specific autoantibodies listed in the ACR SLE classification

criteria—anti-dsDNA, phospholipids, and Sm—should be tested for. Presence of active

nephritis is often accompanied by anti-dsDNA antibodies, and some patients with a history of

thrombosis or recurrent spontaneous abortions may have anti-phospholipid antibodies;

however, many unsuspected patients will also be found to be positive

SSc: Autoantibodies to RNAP I always coexist with anti-RNAP III and RNAP I localizes to the

nucleoli; however, none of the anti-RNAP I/III-positive SSc sera were reported to be nucleolar

staining positive from a hospital laboratory in one study; all sera were reported to be nuclear

speckled that reflected RNAP III staining [10]. Thus, despite earlier reports describing

nucleolar staining by anti-RNAP I antibodies in SSc [48], a report of nucleolar staining should

not be expected all the time [10]. It is reasonable to recommend that all SSc patients with

nuclear speckled and nucleolar patterns should be tested for anti-topo I and RNAP III [1].

Patients with anticentromere patterns may be excluded, because patients with SSc seldom have

more than one SSc-related autoantibody, and it is unlikely that they also have anti-topo I or

anti-RNAP III. Nucleolar staining by anti-U3RNP, Th, and PM-Scl is usually reported as such

from a hospital laboratory in our experience [10]. Anti-topo I may be reported as nucleolar

instead of nuclear, or nuclear plus nucleolar, due to strong nucleolar staining by some sera.

Inclusion of anti-topo I, RNAP III, and centromere will be considered in the classification

criteria of SSc in the future.

DM: The targets of many myositis-specific autoantibodies such as anti-Jo-1 and other tRNA

synthetases and SRP are cytoplasmic antigens [32,33,39]. Unfortunately, they are often not

reported in clinical practice. Anti-Jo-1 for cytoplasmic and anti-U1RNP for nuclear speckled

are the only widely available tests for myositis-related autoantibodies

Although anti-CCP antibodies were first described just ten years ago, and the anti-CCP ELISA

test has only been widely available for a few years, it has rapidly become a standard test in

clinical practice. The frequencies of anti-CCP and rheumatoid factor (RF) are both ~70%;

however, anti-CCP is much more specific for RA. Nevertheless, anti-CCP may be positive in

up to 10–20% of other rheumatic diseases and associated with chronic arthritis or Jaccoud’stype

arthritis in SLE

Sjögren’s syndrome

Anti-Ro/SS-A (60kD) and anti-La/SS-B are detected in ~70% and ~40%, respectively, by

standard tests [1]. These antibodies are included in the European Criteria [51] and should be

tested for when the presence of SjS is suspected

Source

-Antinuclear antibodies in rheumatology