Volume 6, Jul - Sep 2023
Novia Novia 1, Ketut Dewi Kumara Wati 1, Wiradewi Lestari 2
1-Department of Child Health, Prof. Ngoerah Hospital, Faculty of Medicine Universitas Udayana
2-Department of Clinical Pathology Prof. Ngoerah Hospital, Faculty of Medicine Universitas Udayana
Ketut Dewi Kumara Wati, Email: dewi_kumara@unud.ac.id
Background: Pediatric systemic lupus erythematosus (pSLE) has
become increasingly prevalent in pediatric wards, accounting for 10%-20% of all
SLE patients. While the clinical significance of antinuclear antibody (ANA)
immunofluorescence (IF) staining patterns has been reported in relation to
disease presentation, limited research has explored whether different ANA IF
staining patterns are associated with distinct clinical features in pSLE.
Aim: This study aimed to investigate the association between ANA IF staining pattern and clinical manifestations, as well as ANA titer, in pSLE patients.
Methods: ANA-positive pSLE subjects were recruited from the Prof. Ngoerah General Hospital between 2015 and 2022. The association between ANA IF staining pattern and ANA titer was analyzed using the likelihood ratio test. The association between ANA IF staining pattern with organ involvement and specific clinical manifestation was analyzed using the contingency coefficient test. A p-value less than 0.05 was considered significant.
Results: A total of 130 ANA-positive pSLE subjects were included in the study. The female-to-male ratio was 3.3:1, and the median age at diagnosis was 14 ± 3.5 years. Eight types of ANA IF staining patterns were identified, with speckled and homogenous patterns being the most common. The majority of subjects had ANA titers higher than 1:1000. The speckled pattern was evenly distributed across a wide range of titers, while the homogenous pattern tended to be concentrated at higher ANA titers (p=0.004). The gastrohepatology system showed a significant association with ANA IF staining patterns (contingency coefficient 0.720, p<0.001). Additionally, ANA IF staining patterns were significantly associated with ascites, photosensitivity, colitis, and lymphopenia (contingency coefficient 0.372, p=0.007; 0.401, p=0.002; 0.720, p<0.001; 0.348, p=0.022, respectively).
Conclusion: The findings suggest that ANA IF staining patterns are associated with ANA titers, organ involvement, and specific clinical manifestations in pSLE, with potential diagnostic implications.
Keywords: pediatric SLE, antinuclear antibody, ANA IF staining pattern, clinical manifestation, organ system
INTRODUCTION
Systemic lupus
erythematosus (SLE) is a chronic autoimmune disease characterized by the
involvement of multiple organ systems, resulting from a complex interplay of
environmental, hormonal, and genetic factors.1 Pediatric systemic lupus erythematosus (pSLE) has
exhibited a significant rise in prevalence within pediatric healthcare
settings, accounting for approximately 10-20% of all SLE cases.2 Compared to adult-onset SLE, pSLE is known to present
with a more severe clinical course, higher disease activity, and a greater
likelihood of major organ involvement. Consequently, early and accurate
diagnosis of pSLE is crucial for improved prognosis; however, it remains
challenging due to its relatively low prevalence and diverse clinical
manifestations.3–7
Antinuclear
antibodies (ANA) are autoantibodies that target various cellular constituents
and play a crucial role in screening and diagnosing systemic autoimmune rheumatic
diseases (SARDs), including SLE. Despite the longstanding recognition of
autoantibodies in SLE, their precise role in the pathogenesis, diagnosis, and
prognosis of the disease is still an active area of investigation.5,6
Patterns of ANA
staining has been associated with specific nuclear antigens, which in turn have
implications for the clinical presentation of SLE. However, there have been
limited reports regarding the clinical significance of ANA staining patterns
specifically in pSLE patients, and even fewer studies have explored whether
different ANA immunofluorescence (IF) staining patterns may correlate with
distinct clinical features in this population. Therefore, the aim of this study
is to describe the ANA IF staining patterns observed in pSLE patients and
investigate the potential associations between these patterns, ANA titers, and
the clinical manifestations of pSLE. The findings from this study are expected
to enhance our understanding of pSLE and contribute to the improvement of early
diagnosis and treatment strategies.
METHODS
This retrospective
observational study was conducted at Prof. Ngoerah General Hospital, a tertiary
teaching hospital and referral center for pSLE patients in Bali, Indonesia, and
nearby provinces. The study included all patients below 18 years old who were
diagnosed with SLE between 2015 and 2022. Data was collected retrospectively
from the Bali Pediatric Systemic Lupus Erythematosus (BEATLES) database.
Subjects with positive ANA test
were included in the study, while those with incomplete medical records or
comorbidities including infectious or non-infectious causes such as metabolic
or congenital disease that could interfere with clinical presentation at the
time of diagnosis were excluded. Subject characteristics, including gender, age
at diagnosis, year of diagnosis, referral status, origin, ANA titer, and ANA IF
staining pattern at diagnosis were documented.
Clinical manifestations
recorded at the time of diagnosis were recorded to define the clinical spectrum
of the disease. Manifestations were categorized based on system organ
involvement or specific within-organ system manifestations, defined as follow:
-
Hematology
organ involvement comprised of specific clinical manifestations including
leukopenia (WBC count < 4000/mm3), lymphopenia (lymphocyte count
< 1500/mm3), anemia (hemoglobin below normal range based on age;
below 11 g/dL up to 5 years, below 11.5 g/dL from 5-11 years, below 12 g/dL
from 12-14 years or female teenager > 15 years, and below 13 g/dL for male
teenager > 15 years old) and thrombocytopenia (thrombocyte count < 100.000/mm3).8,9
-
Neuropsychiatric
system involvement comprised of specific clinical manifestations, including
seizures, headache, acute confusional state, peripheral neuritis, intracranial
bleeding.
-
Cardiology involvement
comprised of specific clinical manifestations including pericarditis /
pericardial effusion, abnormal valve involvement, cardiomegaly / cardiomyopathy.
-
Pulmonary
involvement comprised of specific clinical manifestations including pleuritis /
pleural effusion.
-
Gastrohepatology
involvement comprised of specific clinical manifestations including raising of
liver enzymes with or without liver enlargement, abdominal pain or abdominal
bleeding unexplained by other condition.
-
Skin and
mucocutaneous involvement comprised of specific clinical manifestations
including malar rash, discoid rash, subcutaneous chronic lupus erythematosus (SCLE)
rash, alopecia, oral ulcers, photosensitivity, Raynaud phenomenon.
-
Musculoskeletal
involvement comprised of specific clinical manifestations regarding any sign of
myositis or arthritis, including swelling, warmth, tender, redness range of
movement limitation on the joint / muscle.
-
Fever: any
raising temperature reported by parents from history taking, documented by
prior hospital or our hospital. As fever might represent certain infectious
disease, we also collect data on the chronicity of the fever onset, pattern of
raising temperature, particularly during the evening or night.
-
Electrolyte
imbalance: any out of normal range of electrolyte level, including sodium
imbalance, potassium imbalance and calcium imbalance.
The presence of at least one
clinical presentation in a particular organ was considered as involvement of
the organ system. Subtypes of ANA IF staining pattern along with its titer
found in our subjects were documented in this study. Descriptive statistics
were used to summarize subject characteristics as numbers and percentages. The
association between ANA IF staining pattern and ANA titer was analyzed using likelihood
ratio test. The association between ANA IF staining pattern and organ
involvement, as well as specific clinical manifestations, was analyzed using
contingency coefficient test. Statistical Package for Social Sciences (SPSS)
version 25.0 was utilized for data analysis. A p-value less than 0.05 was
considered statistically significant.
Ethical clearance was obtained from
the Health Research Ethics Committee of the Faculty of Medicine Universitas Udayana,
and approval was also obtained from Prof. Ngoerah General Hospital.
RESULTS
Demographic and
Clinical Characteristics
A total of 130
subjects who met the study criteria were included in the analysis. The study
population had a female-to-male ratio of 3.3:1, and the median age at diagnosis
was 14 ± 3.5 years. The majority of subjects were referred from other hospitals
and from outside the city of Denpasar.
Figure 1. Research flow
Hematology
involvement was the most common organ involvement, observed in 103 subjects
(85.4%). Anemia was the most common clinical presentation, occurring in 70% of
subjects. ANA immunofluorescence (IF) staining patterns were classified into
eight types, including nuclear (homogenous, speckled, nucleolar, discrete
nuclear dots, and nuclear envelope), cytoplasmic (speckled and fibrillar), and
mitotic patterns (spindle fibers). The most frequently observed pattern among
our subjects was nuclear speckled, and the majority had an ANA titer of more
than 1:1000. Most subjects presented with a single ANA IF staining pattern,
although one subject exhibited three patterns at the time of diagnosis.
Table 1. Subject characteristics
|
Value n(%) |
|
|
Gender |
|
|
Male |
30 (23.1) |
|
Female |
100 (76.9) |
|
Age (years) |
|
|
≤ 5 |
3 (2.3) |
|
6 - 11 |
35 (26.9) |
|
12-18 |
92 (70.8) |
|
Referral |
|
|
Other hospital |
78 (60.0) |
|
Other division |
28 (21.5) |
|
Not referral |
24 (18.5) |
|
Origin |
|
|
Denpasar |
30 (23.1) |
|
Outside Denpasar |
84 (64.6) |
|
Outside Bali |
16 (12.3) |
|
Year of
Diagnosis |
|
|
2015 |
1 (0.8) |
|
2016 |
4 (3.1) |
|
2017 |
5 (3.8) |
|
2018 |
17 (13.1) |
|
2019 |
37 (28.5) |
|
2020 |
28 (21.5) |
|
2021 |
13 (10.0) |
|
2022 |
25 (19.2) |
|
ANA titer |
|
|
1:100 |
39 (30.0) |
|
1:320 |
11 (8.4) |
|
1:1000 |
39 (30.0) |
|
>1:1000 |
69 (53.1) |
|
ANA pattern |
|
|
Homogenous |
56 (43.1) |
|
Speckled |
68 (52.3) |
|
Nucleolar |
6 (4.6) |
|
Cytoplasmic
speckled |
20 (15.4) |
|
Cytoplasmic
fibrillar |
2 (1.5) |
|
Spindle fibers |
1 (0.8) |
|
Discrete nuclear
dots |
3 (2.3) |
|
Nuclear envelope |
1 (0.8) |
|
Number of
patterns |
|
|
Single pattern |
103 (79.2) |
|
Two patterns |
26 (20.0) |
|
Three patterns |
1 (0.8) |
Associations of
ANA IF staining patterns with ANA titer and clinical manifestations
Our findings revealed a significant association between ANA IF staining patterns and ANA titer. The homogenous pattern tended to be more prevalent at higher ANA titers, while the speckled pattern was evenly distributed across all ANA titer groups (p=0.01) (Table 2). The distribution of ANA IF staining patterns across organ involvement categories showed no notable variation (Table 3). However, a significant association was found between the gastrohepatology system and ANA IF staining pattern (contingency coefficient 0.720, p <0.001). Furthermore, specific clinical manifestations, including ascites (0.372, p=0.007), photosensitivity (0.401, p=0.002), colitis (0.720, p <0.001), and lymphopenia (0.348, p=0.022), were significantly associated with ANA IF staining pattern.
Table 2.
Association between ANA IF staining pattern and ANA titer
|
Homogenous (%) |
Speckled (%) |
Nucleolar (%) |
Cytoplasmic speckled (%) |
Cytoplasmic fibrillar (%) |
Spindle fiber (%) |
Discrete nuclear dots (%) |
Nuclear envelope (%) |
n (%) |
p-value |
|
|
1:100 |
6 (10.7) |
26 (38.2) |
1 (16.7) |
3 (15) |
N/A |
N/A |
1 (33.3) |
1 (100) |
39 (30.0) |
0.01 |
|
1:320 |
3 (5.4) |
6 (8.8) |
N/A |
N/A |
1 (50) |
N/A |
1 (33.3) |
N/A |
11 (8.5) |
|
|
1:1000 |
19 (33.5) |
12 (17.6) |
1 (16.7) |
4 (20) |
1 (50) |
1 (100) |
1 (33.3) |
N/A |
39 (37.7) |
|
|
>1:1000 |
28 (50) |
24 (35.3) |
4 (66.6) |
13 (65) |
N/A |
N/A |
N/A |
N/A |
69 (53.1) |
|
|
N (%) |
56 (100) |
68 (100) |
6 (100) |
20 (100) |
2 (100) |
1 (00) |
3 (100) |
1 (100) |
|
|
*N/A:
not available
Table 3. Association
between ANA IF staining pattern and system organ involvement
|
Homogenous
(%) |
Speckled
(%) |
Nucleolar
(%) |
Cytoplasmic
speckled (%) |
Cytoplasmic
fibrillar (%) |
Spindle
fiber (%) |
Discrete
nuclear dots (%) |
Nuclear
envelope (%) |
Homogenous-Speckled
(HS) (%) |
n
(%) |
Contingency
Coefficient |
p
-value |
|
|
Cardiology |
16 (38.1) |
19 (36.5) |
3 (50) |
7 (53.8) |
N/A |
1 (100) |
1 (33.3) |
N/A |
7 (63.6) |
54 (41.5) |
0.237 |
0.461 |
|
Pulmonary |
28 (66.7) |
32 (61.5) |
5 (83.3) |
9 (69.2) |
N/A |
1 (100) |
1 (33.3) |
N/A |
8 (72.7) |
83 (63.8) |
0.228 |
0.522 |
|
Neuropsychiatry |
11 (26.2) |
8 (15.4) |
1 (16.7) |
3 (23.1) |
N/A |
N/A |
N/A |
N/A |
2 (18.2) |
25 (19.2) |
0.159 |
0.908 |
|
Kidney |
31 (73.8) |
29 (55.8) |
3 (50) |
9 (69.2) |
1 (50)) |
1 (100) |
1 (33.3) |
1 (100) |
10 (90.9) |
85 (65.4) |
0.299 |
0.690 |
|
Hematology |
35 (83.3) |
52 (84.6) |
6 (100) |
11 (84.6) |
2 (100) |
1 (100) |
1 (33.3) |
1 (100) |
11 (100) |
111 (85.4) |
0.269 |
0.257 |
|
Gastrohepatology |
17 (40.5) |
16 (30.8) |
N/A |
5 (38.5) |
N/A |
N/A |
N/A |
1 (100) |
1 (9.1) |
40 (30.8) |
0.720 |
<0.001 |
|
Skin and mucocutaneous |
26 (61.9) |
32 (61.5) |
5 (83.3) |
9 (69.2) |
2 (100) |
1 (100) |
3 (100) |
N/A |
10 (90.9) |
87 (66.9) |
0.258 |
0.320 |
|
Musculoskeletal |
25 (59.5) |
26 (50) |
5 (83.3) |
8 (61.5) |
1 (50) |
1 (100) |
2 (66.7) |
N/A |
6 (54.5) |
75 (57.5) |
0.229 |
0.969 |
*N/A:
not available
Table 4. Association
between ANA IF staining pattern and clinical manifestation
|
Clinical
Manifestations |
Homogenous |
Speckled |
Nucleolar |
Cytoplasmic speckled |
Cytoplasmic fibrillar |
Spindle fiber |
Discrete nuclear dots |
Nuclear envelope |
Homogenous-speckled/ HS |
n (%) |
Contingency coefficient |
p-value |
|
Cardiology |
|
|
|
|
|
|
|
|
|
|
|
|
|
Pericarditis |
4 (9.5) |
3 (5.8) |
0 |
3 (23.1) |
N/A |
N/A |
N/A |
N/A |
4 (36.4) |
14 (10.8) |
0.384 |
0.092 |
|
pericardial effusion |
7 (16.7) |
6 (11.5) |
3 (50) |
1 (7.7) |
N/A |
1 (100) |
1 (33.3) |
N/A |
2 (18.2) |
21 (16.2) |
0.402 |
0.069 |
|
Abnormal valve involvement |
2 (4.8) |
7 (13.5) |
1 (16.7) |
3 (23.1) |
N/A |
1 (100) |
1 (33.3) |
N/A |
2 (18.2) |
17 (13.1) |
0.291 |
0.149 |
|
Cardiomegaly |
4 (9.5) |
5 (9.6) |
N/A |
4 (30.8) |
N/A |
N/A |
N/A |
N/A |
1 (9.1) |
14 (10.8) |
0.329 |
0.472 |
|
Cardiomyopathy |
1 (2.4) |
2 (9.6) |
N/A |
N/A |
N/A |
N/A |
1 (33.3) |
N/A |
1 (9.1) |
5 (3.8) |
0.335 |
0.421 |
|
Pulmonary |
|
|
|
|
|
|
|
|
|
|
|
|
|
Pleurisy |
12 (28.6) |
23 (34.6) |
2 (33.3) |
6 (46.2) |
N/A |
N/A |
N/A |
N/A |
7 (63.6) |
46 (35.4) |
0.327 |
0.487 |
|
Pleural effusion |
16 (38.1) |
16 (26.9) |
3 (50) |
3 (23.1) |
N/A |
N/A |
N/A |
N/A |
1 (9.1) |
37 (28.5) |
0.324 |
0.504 |
|
Neuropsychiatry |
|
|
|
|
|
|
|
|
|
|
|
|
|
Headache |
1 (2.4) |
2 (3.8) |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
2 (18.2) |
5 (3.8) |
0.231 |
0.499 |
|
Seizures |
3 (7.1) |
5 (7.7) |
1 (16.7) |
N/A |
N/A |
N/A |
N/A |
N/A |
1 (9.1) |
10 (7.7) |
0.097 |
0.996 |
|
Psychosis |
8 (19) |
4 (7.7) |
1 (16.7) |
1 (7.7) |
N/A |
N/A |
N/A |
N/A |
1 (9.1) |
15 (11.5) |
0.178 |
0.833 |
|
Acute confusional state |
3 (7.1) |
2 (3.8) |
1 (16.7) |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
7 (5.4) |
0.293 |
0.728 |
|
Intracranial hemorrhage |
N/A |
N/A |
N/A |
1 (7.7) |
N/A |
N/A |
N/A |
N/A |
N/A |
1 (0.8) |
0.175 |
0.999 |
|
Kidney |
|
|
|
|
|
|
|
|
|
|
|
|
|
Proteinuria |
26 (61.9) |
24 (46.2) |
2 (33.3) |
4 (30.8) |
N/A |
N/A |
1 (33.3) |
N/A |
8 (72.7) |
65 (50.0) |
0.278 |
0.208 |
|
Hematuria |
18 (42.9) |
17 (32.7) |
2 (33.3) |
6 (46.2) |
N/A |
N/A |
N/A |
N/A |
7 (63.6) |
50 (38.5) |
0.243 |
0.418 |
|
Pyuria |
16 (38.1) |
6 (11.5) |
2 (33.3) |
2 (15.4) |
N/A |
N/A |
N/A |
N/A |
3 (27.3) |
29 (22.3) |
0.293 |
0.143 |
|
Urinary casts |
4 (9.5) |
10 (19.2) |
1 (15.7) |
2 (15.4) |
N/A |
N/A |
N/A |
N/A |
2 (18.2) |
19 (14.6) |
0.148 |
0.939 |
|
Peripheral edema |
15 (35.7) |
10 (19.2) |
N/A |
4 (30.8) |
N/A |
1 (100) |
1 (33.3) |
N/A |
6 (54.5) |
37 (28.5) |
0.298 |
0.123 |
|
Ascites |
12 (28.6) |
4 (7.7) |
N/A |
5 (38.5) |
N/A |
N/A |
N/A |
1 (100) |
N/A |
22 (16.9) |
0.372 |
0.007 |
|
Hypertension |
8 (19) |
3 (5.8) |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
4 (46.4) |
15 (11.5) |
0.311 |
0.084 |
|
Hematology |
|
|
|
|
|
|
|
|
|
|
|
|
|
Leukopenia |
14 (33.3) |
12 (23.1) |
3 (50) |
4 (30.8) |
N/A |
N/A |
N/A |
N/A |
3 (27.3) |
36 (27.7) |
0.194 |
0.750 |
|
Lymphopenia |
23 (54.8) |
22 (42.3) |
6 (100) |
7 (53.8) |
N/A |
N/A |
1 (33.3) |
N/A |
10 (90.9) |
69 (53.1) |
0.348 |
0.022 |
|
Anemia |
31 (73.8) |
34 (65.4) |
3 (50) |
11 (84.6) |
2 (100) |
1 (100) |
N/A |
1 (100) |
9 (81.8) |
91 (70.0) |
0.294 |
0.138 |
|
Thrombocytopenia |
11 (26.2) |
9 (17.3) |
1 (16.7) |
1 (7.7) |
N/A |
N/A |
N/A |
N/A |
3 (27.3) |
25 (19.2) |
0.182 |
0.813 |
|
Gastrohepatology |
|
|
|
|
|
|
|
|
|
|
|
|
|
Transaminitis |
17 (40.5) |
16 (30.8) |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
1 (9.1) |
39 (30.0) |
0.268 |
0.259 |
|
Colitis |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
1 (100) |
N/A |
1 (0.8) |
0.707 |
<0.001 |
|
Skin and mucocutaneous |
|
|
|
|
|
|
|
|
|
|
|
|
|
Malar rash |
13 (31) |
20 (38.5) |
4 (66.7) |
4 (30.8) |
N/A |
N/A |
N/A |
N/A |
7 (63.6) |
48 (36.9) |
0.291 |
0.741 |
|
Discoid rash |
1 (2.4) |
1 (1.9) |
N/A |
2 (15.4) |
N/A |
N/A |
N/A |
N/A |
N/A |
5 (3.8) |
0.236 |
0.470 |
|
SCLE rash |
5 (11.9) |
13 (25) |
1 (16.7) |
3 (23.1) |
N/A |
1 (100) |
1 (33.3) |
N/A |
3 (27.3) |
27 (20.8) |
0.235 |
0.475 |
|
Alopecia |
19 (45.2) |
23 (44.2) |
3 (50) |
7 (53.8) |
1 (100) |
N/A |
1 (33.3) |
N/A |
8 (72.7) |
62 (47.7) |
0.218 |
0.592 |
|
Oral ulcer |
12 (28.6) |
14 (26.9) |
3 (50) |
3 (23.1) |
1 (100) |
N/A |
N/A |
N/A |
3 (27.3) |
36 (27.7) |
0.213 |
0.626 |
|
Photosensitivity |
5 (11.9) |
4 (7.7) |
2 (33.3) |
1 (7.7) |
N/A |
N/A |
3 (100) |
N/A |
3 (27.3) |
18 (13.8) |
0.401 |
0.002 |
|
Raynaud phenomenon |
1 (2.4) |
2 (3.8) |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
3 (2.3) |
0.162 |
1.000 |
|
Epistaxis |
1 (2.4) |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
1 (0.8) |
0.150 |
1.000 |
|
Musculosceletal |
|
|
|
|
|
|
|
|
|
|
|
|
|
Arthritis |
25 (59.5) |
26 (50) |
5 (83.3) |
8 (61.5) |
1 (50) |
1 (100) |
2 (66.7) |
N/A |
6 (54.5) |
74 (56.9) |
0.229 |
0.969 |
|
Myositis |
N/A |
1 (1.9) |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
1 (0.8) |
0.229 |
0.969 |
|
Electrolyte imbalance |
|
|
|
|
|
|
|
|
|
|
|
|
|
Sodium imbalance |
10 (23.8) |
10 (19.2) |
2 (4.8) |
N/A |
N/A |
N/A |
N/A |
N/A |
1 (9.1) |
25 (19.2) |
0.232 |
0.965 |
|
Potassium imbalance |
7 (16.7) |
8 (15.3) |
N/A |
3 (23) |
N/A |
N/A |
N/A |
N/A |
1 (9.1) |
19 (14.6) |
0.214 |
0.985 |
|
Calcium imbalance |
19 (45.2) |
15 (28.8) |
2 (33.3) |
6 (46.2) |
N/A |
N/A |
N/A |
N/A |
2 (18.2) |
44 (33.8) |
0.243 |
0.417 |
|
Fever |
18 (42.9) |
22 (42.3) |
4 (66.7) |
3 (23.1) |
N/A |
N/A |
N/A |
N/A |
4 (36.4) |
51 (39.2) |
0.236 |
0.467 |
*N/A: not available
DISCUSSION
This restrospective study
aimed to investigate the association between ANA IF staining patterns, ANA
titers, and clinical manifestations in order to identify potential diagnostic
and prognostic implications for pSLE. We documented
130 ANA positive pSLE cases from 2015 to 2022, with a median age at diagnosis
of 14 ± 3.5 years old and a female to male ratio of 3.3:1. Consistent with
previous studies, our results revealed a high prevalence of anemia and
hematology involvement in pSLE patients, followed by skin/mucocutaneous and
kidney involvement.7,10–12
The International Consensus on ANA Patterns (ICAP) has divided ANA IF staining pattern into 29 discrete HEp-2 cell IIF patterns on expert level and 13 subtypes on competent level. The distribution of ANA patterns in SLE may vary depending on clinical and ethnic differences, as reported in earlier studies.13 Eight types of ANA IF staining pattern were identified in our study, distributed into three main types of patterns: nuclear, cytoplasmic, and mitotic patterns. This study demonstrated that the speckled and homogenous patterns were the most common ANA IF staining patterns, which aligns with findings in both adult and pediatric SLE populations.14–16 Rare ANA IF staining patterns (frequency less than 1%) were also found in our subjects, including nuclear envelope and spindle fibers.17
We observed a significant association
between ANA IF staining patterns and ANA titers. The speckled pattern was
distributed across a wide range of titers, whereas the homogenous pattern was
more concentrated at higher titers, particularly at 1:1000 or higher. This
finding suggests a potential association between the intensity of ANA staining
which indicated by higher titers, and organ involvements in pSLE.
Previous studies have suggested that
ANA-IF staining pattern is correlated with specific autoantibodies, which may
be related to particular clinical symptoms. Our findings showed associations
between ANA IF staining patterns and specific clinical manifestations. Notably,
the gastrohepatology organ system showed a significant association with ANA
staining patterns, specifically the nuclear envelope pattern. This association
may be linked to clinical manifestations such as colitis and differences in the
distribution of ANA patterns in transaminitis. We also found significant
associations were found between ANA staining patterns and clinical
manifestations, including photosensitivity, colitis, ascites, and lymphopenia.
Photosensitivity was commonly presented
with homogenous, speckled, or HS pattern and in all discrete nuclear dots
pattern (100%). Colitis was probably associated with nuclear envelope pattern,
and mixed pattern was more likely presented along with lymphopenia, though it
could be presented as homogenous or speckled pattern alone. Ascites was
commonly distributed in homogenous pattern, similar to serositis in other
organs such as pericardial effusion or pleural effusion. These findings were
statistically significant (p value < 0.05). These findings align with
previous reports and highlight the potential diagnostic and prognostic value of
ANA IF staining patterns in pSLE.18,19
The association between ANA IF staining
pattern and clinical manifestation was statistically significant in accordance with Frodlund, et al. who showed that central nervous
system was less often associated with homogenous pattern compared to other
staining patterns, whereas arthritis and organ damage respectively were less
often associated with speckled pattern and photosensitivity was significantly
associated with anti-Ro/SSA antibodies which was more often associated with
mixed (HS pattern).18
Previous
studies have reported that lymphopenia is associated with increased disease
activity and organ damage indices, as noted by Faddah et al.20 Additionally,
Mughales et al. found that the mixed pattern was associated with the highest
levels of lupus anticoagulant.14 Consistent
with these findings, our study found that lymphopenia was frequently presented
in HS pattern, although presentation with homogenous or speckled pattern was also
possible. This may suggest that more antibodies were involved in the
development of lymphopenia, which could reflect a more aggressive course of the
disease.
Study Limitations
-
As our study was retrospective, some
clinical features could not be specifically identified from the medical
records, such as cardiomegaly without further evaluation with echocardiography.
-
The association of ANA IF staining pattern
to a particular clinical manifestation in our study may reduce its clinical
utility. Analyzing the association between staining pattern and a collection of
symptoms as included in the disease activity index (SLEDAI) or damage index
(SDI) may help extend its clinical relevance.
Implication and Recommendations
-
Children and adolescents with homogenous
ANA IF staining pattern should be evaluated for ascites and serositis in lungs
and heart, as these may be related to severe manifestations that increase the
risk of mortality.
-
Children and adolescents with discrete
nuclear dots ANA IF staining pattern should be informed about the risk of
excessive activity under sunlight, and adequate protection should be provided
to prevent photosensitivity.
-
Children and adolescents with rare
patterns should be evaluated for the possibility of unusual presentations, such
as colitis with nuclear envelope pattern.
-
Children and adolescents with
presentations of more than one pattern, especially with the combination of the
two most common patterns (homogenous and speckled - HS pattern), should raise
awareness of the possibility of a more severe clinical course and lead to the
investigation of lymphopenia.
CONCLUSION
Our study
highlights the association between ANA IF staining patterns, ANA titer, and
clinical manifestations in pSLE. These findings suggest potential diagnostic
implications to a certain extent. Further exploration of these relationships
and their potential clinical significance is warranted.
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