diagnostic tests in rheumatic disease: what’s old, what’s ......driven by globulin and...
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Diagnostic Tests in Rheumatic Disease:
What’s Old, What’s New & What’s
Useful?
Robert H. Shmerling, M.D.
Beth Israel Deaconess Medical Center
Boston, MA
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Diagnostic Tests in Rheumatic Disease:
What's Old, What's New, What's Useful
1. Introduction 4. ANA
2. ESR & CRP 5. ANCA
3. RF & anti-CCP (& MBDA) 6. Imaging StudiesCOPYRIGHT
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§ Diagnostic tests rarely establish a diagnosis in
rheumatic disease and frequently provide more
prognostic than diagnostic information.
§ Sensitivity and specificity are a good start: they are
available for many tests and are not dependent on
prevalence of disease.
§ Predictive value is the most useful characteristic of a
test but varies with disease prevalence (or pre-test
probability) – it is highly dependent on judgment.
§ The rheumatic disease criteria help standardize
studies but have limitations - milder disease may be
excluded.
DIAGNOSTIC TESTS: INTRODUCTION
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Wetalkalotaboutwhichteststoorderin
whichdiseases.
But,wealmostnevertalkabout
whether toordertests…
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• Sensitiveforsystemicinflammation,drivenbyglobulinandfibrinogen
- Loweredbypolycythemia,lowfibrinogen,spherocytosis,sicklecells
• Non-specific- ThatincludestheESR>100
• Riseswithage:normal=age/2(see:AnnInternMed1986;104:515)
• Riseswithpregnancy,infection,malignancy,paraproteinemia,anemia
• Bepreparedtodealwiththeunexpectedresults
(SUO*versusfalsenegative)
*Sedrateofunknownorigin
ERYTHROCYTE
SEDIMENTATION RATE
(ESR)
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The ESR: How it’s done
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Rheumatic Disease
• Giant Cell Arteritis, Polymyalgia
Rheumatica (PMR) - high
sensitivity, useful as adjunct to monitor course
• Other diseases – variable, somewhat unreliable
Non-rheumatic Disease
• Subacute Bacterial Endocarditis - high sensitivity
• Other diseases - may be helpful in monitoring
treatment of osteomyelitis, inflammatory bowel
disease, abscess
ERYTHROCYTE
SEDIMENTATION
RATE (ESR)
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C-REACTIVE PROTEIN (CRP)
• What’s with the name? à Discovered by
precipitation with the c-polysaccharide of the
pneumococcus
• Conserved in evolution – perhaps it’s more important than
we know
• reflects inflammation/disease activity; can change over
hours (much faster & greater range than ESR)
• CRP tends not to rise much in lupus unless infection
present -(see Firooz N, et al, Lupus 2011 20: 588)
• elevations in CRP may identify cardiac risk
• unknown: Is CRP better for assessing disease severity or
predicting prognosis than ESR? What if they are
discordant?
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ESRvs.CRP
Adapted from: Best Practice Advocacy Centre New Zealand
http://www.bpac.org.nz/resources/campaign/crp_esr/crp_esr_rem.asp
ESR CRP
Gender (Female) X
Age X
Pregnancy X
Drugs(e.g.,steroids,
NSAIDs)
Smoking X
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• CRP more sensitive (98.9% vs. 91.5%) and predicted
relapse better than ESR
• ESR reflected response to treatment better (ESR high in
13%, CRP in 42% after 4 weeks of treatment)
• IL-6 was even better: persistent elevation predicted relapse
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Kermanietal.SeminArthritisRheum.2012;41:866
ESRvs.CRPforTemporalArteritis
• 764patientswithESR,CRP&temporalarterybiopsy(23%of
whichwerepositive)
• SensitivityofCRP=87%
• SensitivityofESR=84%
• Only7patients(4%)with
apositiveTABforGCA
hadanormalESRand
CRP
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Symmetric, persistent polyarthritis in “rheumatoid distribution”
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RHEUMATOIDFACTOR
• Considered helpful: sensitive and
specific, reliable, inexpensive,
included among criteria for RA, present in other
rheumatic disease.
However,
• Sensitivity & specificity in RA are modest
• False positive test results are common
& may outnumber true positive test results in many
primary care settings.
• Prognostic information likely outweighs diagnostic
information and results do not affect management; a
recent study found less prognostic utility - likely due to
improved treatment (ArthritisCareRes2017,69:1809)
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Rheumaticdiseasesassociatedwitha
positiverheumatoidfactor
Disease Sensitivity
• Rheumatoidarthritis 50-90%
• SLE 15-35%
• Sjogren'ssyndrome 75-95%
• Systemicsclerosis 20-30%
• Polymyositis/
dermatomyositis 5-10%
• Cryoglobulinemia 40-100%
• Mixedconnective 50-60%
tissuedisease
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Non-rheumatic
conditions
associatedwitha
positive
rheumatoid
factor
Aging(>age70) 10-25%
InfectionBacterialendocarditis 25-50%Liverdisease 15-40%Tuberculosis 10%Syphilis upto10%Parasiticdisease upto90%Leprosy upto60%Viralinfection upto60%
PulmonaryDiseaseSarcoidosis 3-33%Interstitialpulm.fibrosis 10-50%Silicosis 30-50%Asbestosis 30%
MiscellaneousDiseasesPrimarybiliarycirrhosis 45-70%Malignancy 5-25%
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Pre-testprobabilitymakesallthe
differenceBasedonSens =0.7&Spec=0.85forRFinRA:
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RheumatoidFactorSummary
• Moderately sensitive and specific
• Higher titers have higher specificity and
positive predictive value
• Positive predictive value is low in most non-specialty settings
• A negative test does not rule out disease (20-50% of RA patients are seronegative)
• High titer RF without rheumatic disease:
think of cryoglobulinemia and SBE
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Anti-cyclic citrullinated protein (anti-CCP)
• Anti-CCP antibodies - target citrulline,
a modified form of arginine
• Sensitivity = 50-70%
• Specificity = 95-98%, correlates with
erosive disease, can be present before symptoms
• May identify some RF-negative RA patients
• May identify some “false+ RF” patients (e.g., negative in
patients with Hep. C)
• ?Pathogenic - modest sensitivity argues against
The bottom line: anti-CCP useful given its higher
specificity but RA cannot be diagnosed by a blood test.
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AnnInternMed.2007;146:797-808.
• Meta-analysisof86studies:
• Sensitivitywassimilarforthe2tests(67%vs.69%)
• Specificityofanti-CCPwashigherthanRF(95%vs.
85%)
• “…anti-CCPantibodypositivityismorespecificthan
IgMRFpositivityfordiagnosingrheumatoidarthritis
andearlyrheumatoidarthritis.”
AnnInternMed2007;146:797
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Criteria for RAThe 2010 American College of Rheumatology/European
League Against Rheumatism classification criteria for
RA
Criteria to apply to those who:
• have at least 1 joint with definite clinical synovitis
• synovitis not better explained by another disease
A score of 6 out of 10 is needed for classification of a
patient as having definite RA
A. Joint involvement -
1 large joint: 0
2-10 large joints: 1
1-3 small joints: 2
4-10 small joints: 3
>10 joints (at least 1 small joint): 5
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B. Serology –• RF and anti-CCP both negative: 0• Low titer positive RF or anti-CCP: 2• High titer RF or anti-CCP: 3
C. Acute-phase reactants• CRP and ESR both normal: 0• Either CRP or ESR elevated: 1
D. Duration of symptoms<6 weeks: 0> 6 weeks: 1
Criteria for RA (continued)
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SomethingNew:multiplebiomarkerdisease
activity(MBDA)testing
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MBDAtesting:Vectraexample
• 12biomarkers,includingCRP,
IL-6,serumamyloidA(largest
contributorstoscore)
• Vectrascorescorrelatewith
clinicalmeasuresofdisease
activity(e.g.,DAS28),x-ray
changes
• Notfordiagnosis,onlyfor
diseaseactivity
• Expensive:$1000/test
• Marginalbenefituncertain
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Photosensitive, malar rash sparing nasolabial fold,
alopecia
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ANASENSITIVITYINSELECTEDDISORDERS
DISEASE ANAsensitivity
Systemiclupuserythematosus 95-99%
Drug-inducedlupus 100%
Sjogren’sSyndrome 75%
Scleroderma 50-90%
MCTD 99-100%
RA 20-40%
Other: autoimmune thyroid disease, hepatitis, PBC, infections
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ANTINUCLEARANTIBODIES
Usefultoknow:
§ TheANAishighlysensitive(95-99%)inSLE,low
specificity,labvariability;alsosensitiveforSjogren’s
Syndrome,Scleroderma,Drug-InducedLupus
Maybehelpfultoknow:
§ ThehighertheANAtiter,themorelikelytheresultisa
truepositive
Probablyuseless:
§ TheANApattern(diffuse,speckled,peripheral,
nucleolar)
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Peripheral or Rim: anti-dsDNA Diffuse: nonspecific
Speckled: anti-Ro or anti-Sm Nucleolar: anti-RNA
Antinuclear antibody (ANA) Patterns
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WhataboutthoseotherANAs?
Alsocalledspecificautoantibodies,extractablenuclearantigens(ENAs),ANA“panel”
• Anti-ds-DNA (peripheral)andanti-Smith (speckled)arehighlyspecific,butnotsensitive,forSLE
• Anti-Ro crossesplacentaandmediatescongenitalCHB,neonatallupus;commoninSjogren’sdisease,Scleroderma
• Anti-RNP (speckled)typicallypositiveinMixedConnectiveTissueDisease
• Anti-histone (diffuse)commonindrug-inducedlupus&SLE
• Anypattern/specificitymaybenotedinSLE
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Antineutrophilic cytoplasmic antibody (ANCA)
c-ANCA (cytoplasmic) p-ANCA (peri-nuclear)Usually anti-
proteinase-3
(PR-3)
Often anti-
myeloperoxidase
(MPO)
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Rheumatic Disease: c-ANCA/PR3 p-ANCA/MPO
Granulomatosis with polyangiitis 80% 10%
Microscopic polyangiitis 20% 50%
Eosinophilic Granulomatosis
with polyangiitis 10% 40%
Other vasculitides generally ANCA-negative: hypersensitivity, Henoch-Schönlein purpura (HSP), polyarteritis nodosa, GCA, Takayasu’s
ANTI-NEUTROPHIL CYTOPLASMIC
ANTIBODIES (ANCA)
Note: drug-induced vasculitis (especially PTU, hydralazine,
minocycline) also associated with +p-ANCA/MPO; tainted cocaine
may have both anti-MPO and anti-PR3
RA, SLE, Sjogren’s, other rheumatic disease may be associated
with nonspecific p-ANCAs (not directed against MPO)
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ANTI-NEUTROPHILCYTOPLASMICANTIBODIES(ANCA)
ANCAinnon-rheumaticdisease: cANCA/ pANCA/
PR-3 MPO
Idiopathiccrescenticglomerulonephritis10-20% 65-75%
Anti-GBMDisease 10% 30-40%
Nonspecific pANCAs (that is, not directed against MPO) also observed in:
• Ulcerative colitis
• Primary sclerosing cholangitis
• Cystic Fibrosis
• Autoimmune hepatitis
• Infection: leprosy, malaria, SBE
• (Pre)eclampsia, diffuse alveolar hemorrhage, graft-versus-host disease
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CanariseinANCAtiterpredictflare?
Inaggregate,ariseinANCAcorrelateswithfutureflarebutfor
anindividualpatienttheimpactismodest;similarfor
persistentANCA.
Bottomline:monitoringANCAlevelsnotparticularlyhelpful
Tomasson etal.Rheumatology (Oxford).2012;51:100
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ANCA:Summary• ItisnotenoughtoknowthattheANCAispositive- anti-PR3andAnti-MPOarehighlyspecificforcrescenticGN,GPA(WG),relatedvasculitides
• Intheproperclinicalsetting,ANCAresultsmay beenoughtowarranttreatmentwithoutbiopsy(butsuchsettingsareprobablyrare)
• Sensitivityandspecificityaregoodbutnotperfect
• AnegativeANCAistheruleinlargestandsmallestvesselvasculitides
• ForpatientswithANCA-associatedvasculitis,monitoringANCAlevelsdonotreliablypredictrelapseorreflectdiseaseactivity
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Ultrasound in joint and tendon disease
Fluid Thickening
Normal
TendonitisCOPYRIGHT
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Erosion by MRI & US, missed by radiograph
X-ray
MRI
Ultrasound and MRI:
Sensitive for early erosions
in inflammatory joint disease
Ultrasound
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Ultrasound findings in gout & CPPD (pseudogout)
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Ultrasound-guided joint aspiration
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MRI
inflammatory muscle disease
(myositis)
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http://therheumatologypodcast.com/podcast/dual-energy-ct-for-diagnosis-of-gout
DualenergyCTfordiagnosisofgout
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DIAGNOSTICTESTSINRHEUMATICDISEASE
• Most“diagnostictests”inrheumaticdiseasearenotdiagnosticandhavesignificantlimitations
• Selectivetesting,ratherthanordering“panels,”tendstoprovidemoreusefulinformation
• AvoidthetemptationtocheckANA,RF,ESRineverypatientwitharthralgia,orANCAforeverypatientwithpossiblevasculitis
• Testingto“rule-out”diseaseinsettingsoflowlikelihoodisoftenunhelpful- anegativetestoftendoesnotexcludediseaseandapositivetestmaybeconfusing
• Anti-CCPisthefirsthighlyspecificbiomarkerforRA
• Don’tavoidchecking“non-exotic”labs,e.g.,urinalysis,CBCrenalfunction
• Considertimeasadiagnostictestofchoice
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DIAGNOSTICTESTSINRHEUMATICDISEASE(2)
• What’sold?ESR,RF,ANA,ANCA,radiographs
• What’snew(er)?CRP,anti-CCP,MSKUS,MRI
• Anti-CCPisthefirsthighlyspecificbiomarkerforRA
• What’suseful?Eachoneoftheabovewhenordered
selectivelyandinterpretedinlightofknownlimitations
• Standby:
• CRPvs.ESR?
• HowbesttoassessRAdiseaseactivity?
• RoutineofficeuseofmusculoskeletalUS?
• DualenergyCTforgout?
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Thanksforyourattention!
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