Connective Tissue Diseases

  • Diagnosis
  • Algorithms
  • Monitoring
  • Background
  • Pediatrics
  • Lab Tests
  • References
  • Related Topics

Indications for Testing

  • Patient with systemic symptoms, including arthralgias, arthritis, skin rashes, anemia, renal dysfunction, pleuritis, pericarditis

Laboratory Testing

  • Nonspecific testing
    • CBC – rule out infection
    • C-reactive protein (CRP)
    • Antinuclear antibodies (ANA) testing
      •  ANA, IgA, by ELISA
        • Negative – possible scenarios
          • No connective tissue disease (CTD) present
          • False-negative result – consider systemic sclerosis (scleroderma SSc), polymyositis/dermatomyositis (PM/DM), inactive systemic lupus erythematosus (SLE)
            • If strong suspicion for CTD, consider disease-specific antibody tests or panels
          • Positive – ANA HEp-2, IgG, by IFA (result pattern suggests underlying disease)
            • ANA reported patterns and diagnoses
              • Centromere – limited cutaneous scleroderma (lcSSc), CREST (calcinosis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, telangiectasia)
              • Cytoplasmic – PM, DM, SLE, SSc
              • Peripheral/rim/homogenous – SLE, drug-induced lupus erythematosus (DIL)
              • Nucleolar – SLE, SSc, PM DM
              • Speckled – SLE, Sjögren syndrome, mixed connective tissue disease (MCTD)/undifferentiated connective tissue disease (UCTD), diffuse cutaneous scleroderma (dcSSc), unidentified specificities or markers of low prevalence in CTD – see Connective Tissue Disease Testing Algorithm for more specific antibody testing patterns
            • False-positive results may be induced by age, certain infections, cancers, and drugs
            • ANA may be positive in inflammatory diseases (eg, autoimmune liver diseases)
            • Titer level has no bearing on diagnosis or disease severity once it is above established normal level
    • Other testing
      • Rheumatoid factor IgM antibodies – if musculoskeletal complaints are present
      • If suspicion for connective tissue disease is low, consider drug-induced lupus erythematosus (DIL), chronic autoimmune disease, chronic hepatitis C virus
      • Urinalysis – rule out glomerulonephritis associated with connective tissue disease
      • Anti-neutrophil cytoplasmic antibodies (ANCA) – rule out vasculitis associated with connective tissue disease

Differential Diagnosis

  • Once diagnosis has been made, use monitoring tests based on organ involvement
    • Urinalysis – acceptable screen for renal disease
    • If cytopenias present, follow with sequential CBCs
    • Certain treatment drugs require liver function testing

Several autoimmune connective tissue diseases may present with similar features. These diseases include systemic lupus erythematosus, Sjögren syndrome, mixed connective tissue disease, systemic sclerosis (scleroderma), inflammatory myopathies (polymyositis/dermatomyositis [PM/DM]), and undifferentiated connective tissue disease.

Epidemiology

  • Incidence – 15-50/100,000, depending on disease
  • Age – onset is 15-40 years; peak onset in 20s
  • Sex – M<F, 1:6-10

Pathophysiology

  • Circulating antigen-antibody complexes affect a variety of organs
  • Multisystem disease presentation
  • Antigen/antibody complexes affect a variety of organs in connective tissue diseases
  • ANA antibodies are the most common antibodies and may precede the onset of connective tissue disease
  • Certain antibodies may show specificity for certain diseases (eg, SSA 52, SSA 60, and SSB antibodies for Sjögren syndrome)
  • ANA antibodies are not specific for connective tissue disease and may also be associated with
    • Infectious diseases
    • Cancers
    • Other autoimmune disorders (eg, autoimmune liver disease)
    • Advanced age

Clinical Presentation

  • Cardiopulmonary – pleuritis, pericarditis, fibrosis, chest pain
  • Constitutional – fever, anorexia, weight loss
  • Dermatologic – skin rashes, Raynaud phenomenon, photosensitivity
  • Gastrointestinal – gastroesophageal reflux disease
  • Hematologic – cytopenias (involving neutrophils, erythrocytes, and platelets)
  • Musculoskeletal – arthralgias, arthritis, synovitis, myopathy
  • Neurologic – seizures, encephalopathy
  • Otorhinolaryngologic – sicca syndrome, oral ulcers
  • Renal – proteinuria, glomerulonephritis

Clinical Background

Epidemiology

  • Incidence – varies by disease but lower than in adults
  • Sex – M<F for most disorders
  • Age – presents more often >10 years

Clinical Presentation

  • Cardiopulmonary – chest pain, pericarditis, pleuritis
  • Constitutional – fever, anorexia, weight loss (most common)
  • Dermatologic – skin rash, Raynaud syndrome, photosensitivity
  • Gastrointestinal – abdomen pain, diarrhea, hepatitis
  • Musculoskeletal – arthralgias, arthritis, synovitis, myopathy, weakness

Diagnosis

Indications for Testing

  • Appropriate clinical presentation, including arthritis, arthralgias, skin rashes, anemia, pleuritis, pericarditis

Laboratory Testing

  • Nonspecific testing
    • Refer to Diagnosis tab
  • ANA testing
    • Refer to Diagnosis tab and Connective Tissue Disease Testing Algorithm
  • Other testing
    • Rheumatoid factor IgM antibodies – rule out juvenile idiopathic arthritis if musculoskeletal complaints are present

Differential Diagnosis

Tests generally appear in the order most useful for common clinical situations. Click on number for test-specific information in the ARUP Laboratory Test Directory.

Anti-Nuclear Antibodies (ANA), IgG by ELISA with Reflex to ANA, IgG by IFA 0050080
Method: Qualitative Enzyme-Linked Immunosorbent Assay/Semi-Quantitative Indirect Fluorescent Antibody

Recommended Use 

Aid in initial diagnosis of connective tissue disease

Detects antibodies against dsDNA, histone, SS-A (Ro), SS-B (La), Smith, snRNP/Sm, Scl-70, Jo-1, centromere, and an extract of lysed HEp-2 cells

Reflex pattern – if ANA are detected by ELISA, then ANA by IFA titer will be added

Limitations 

Results are not disease specific

ANA ELISA assays have lower sensitivities for antibodies associated with nucleolar and specked ANA-IFA patterns

Anti-Nuclear Antibody (ANA), IgG by IFA with Reflex by IFA Pattern 2008467
Method: Semi-Quantitative Indirect Fluorescent Antibody/Qualitative Enzyme-Linked Immunosorbent Assay/Semi-Quantitative Enzyme-Linked Immunosorbent Assay/Semi-Quantitative Multiplex Bead Assay/Semi-Quantitative Immunoblot

Recommended Use 

Initial screen for autoimmune connective tissue diseases

One or more reflexive tests may be added, depending on the ANA pattern detected

Limitations 

Only cytoplasmic, nuclear mitotic apparatus (NuMA), and/or nuclear dot pattern will be reported if observed

Titers are not performed

Dual or mixed patterns will not be reflexed; additional testing for dual or mixed patterns should be determined by the ordering physician

A negative ANA by IFA test does not rule out the presence of connective tissue disease 

Connective Tissue Diseases Profile 0051668
Method: Semi-Quantitative Multiplex Bead Assay

Recommended Use 

Confirmatory tests for specific and more common connective tissue disease

Components include Sm (ENA) antibody; RNP (U1) (ribonucleic protein); SSA (Ro); SSB (La); Jo-1; ribosomal P protein; centromere; and scleroderma (Scl-70)

Systemic Scleroderma Comprehensive Panel 2013325
Method: Semi-Quantitative Immunoblot/Semi-Quantitative Indirect Fluorescent Antibody/Semi-Quantitative Multiplex Bead Assay/Semi-Quantitative Enzyme-Linked Immunosorbent Assay

Recommended Use 

Comprehensive evaluation of systemic sclerosis (SSc)

Indicated when suspicion for SSc is high and patient presents with features of overlap disease

Panel includes anti-nuclear antibody (ANA) titer, anti-nuclear antibody (ANA) pattern, anti-Scl-70, anti-RNA polymerase III antibody, anti-centromere antibody, anti-U1 RNP antibody, anti-fibrillarin (U3 RNP), anti-PM/Scl antibody

Clinical sensitivity for ANA by IFA for SSc ranges from 90-95%; sensitivity for individual SSc-specific marker is dependent on ethnicity 

Limitations 

Negative antibody test result does not exclude SSc; 5-10% of SSc patients are ANA IFA negative

Panel does not include Th/To

Multiplex bead assay detects antibodies targeting the centromere protein B of the centromere complex

Systemic Sclerosis Panel 2012057
Method: Semi-Quantitative Indirect Fluorescent Antibody/Semi-Quantitative Multiplex Bead Assay/ Semi-Quantitative Enzyme-Linked Immunosorbent Assay

Recommended Use 

Indicated for patients with distinct features of SSc

Reflex pattern – if ANA IFA is positive and SSc specific markers are negative, testing for other markers associated with SSc or connective tissue disease based on observed ANA IFA pattern(s) is performed (ethnicity or clinical presentation may be clinically useful)

Components include anti-nuclear antibody (ANA) by IFA, IgG; scleroderma (Scl-70) antibody, IgG; and RNA polymerase III antibody, IgG

Clinical sensitivity for ANA by IFA for SSc ranges from 90-95%; sensitivity for individual SSc-specific marker is dependent on ethnicity

Limitations 

Negative antibody test result does not exclude systemic sclerosis

Panel does not include Th/To

Myositis-Specific Antibody Panel 2010862
Method: Qualitative Immunoprecipitation/Semi-Quantitative Multiplex Bead Assay

Recommended Use 

Differential evaluation of patients with polymyositis/dermatomyositis (PM/DM), necrotizing autoimmune myopathy, connective tissue diseases, and/or overlap syndrome in conjunction with muscle biopsy and clinical presentation

Most useful if suspicion for inflammatory myopathy is high (eg, antisynthetase syndrome, necrotizing autoimmune myopathy, DM) 

Components include Jo-1; Mi-2; PL-7; PL-12; P155/140; EJ; SRP; and OJ

Limitations 

Results by themselves are not diagnostic; strong clinical correlation is recommended

Negative results do not rule out a diagnosis of IM or overlap syndrome

Myositis Antibody Comprehensive Panel 2010851
Method: Qualitative Immunoprecipitation/Semi-Quantitative Multiplex Bead Assay

Recommended Use 

Most useful if general suspicion for inflammatory myopathy exists, including overlap syndrome

Components include PM/Scl-100; SSA 52 and 60 (Ro) (ENA) IgG; RNP (U1) (ribonucleic protein) (ENA) IgG; Jo-1 IgG; Mi-2; PL-7; PL-12; P155/140; EJ; SRP; Ku; U2; and OJ

Limitations 

Results by themselves are not diagnostic; strong clinical correlation is recommended

Negative results do not rule out a diagnosis of IM or overlap syndromes 

Rheumatoid Arthritis Panel 2003277
Method: Semi-Quantitative Enzyme-Linked Immunosorbent Assay/Immunoturbidimetry

Recommended Use 

Preferred panel for the workup of suspected rheumatoid arthritis or undifferentiated inflammatory arthritides

Components include cyclic citrullinated peptide (CCP) antibody, IgG, and rheumatoid factor

Fibrillarin (U3 RNP) Antibody, IgG 2012173
Method: Semi-Quantitative Immunoblot

Recommended Use 

Recommended for the diagnosis of systemic sclerosis in patients negative for centromere, Scl-70, or RNA polymerase III antibodies

May predict skeletal muscle involvement and pulmonary arterial hypertension

Limitations 

Negative test result does not rule out the diagnosis of systemic sclerosis

Test results alone are not diagnostic; results should be used in conjunction with other laboratory tests and clinical findings

Anti-Neutrophil Cytoplasmic Antibody with Reflex to Titer and MPO/PR-3 Antibodies 2002068
Method: Semi-Quantitative Indirect Fluorescent Antibody/Semi-Quantitative Multiplex Bead Assay

Recommended Use 

Preferred reflex panel for managing patients with a known diagnosis of vasculitis; may be assistive in evaluating suspected vasculitis
For the workup of suspected vasculitis, the preferred panel is ANCA-associated vasculitis profile (ANCA/MPO/PR-3) with reflex to ANCA titer

Panel includes ANCA, IgG; myeloperoxidase antibody and serine protease 3 antibody

Reflex pattern – if screen is positive, titer and MPO/PR-3 antibodies testing will be added

Guidelines

American Society for Clinical Pathology. Choosing Wisely - Five Things Physicians and Patients Should Question. An initiative of the ABIM Foundation. [Last revision Feb 2015; Accessed: Jan 2016]

Meroni PL, Schur PH. ANA screening: an old test with new recommendations. Ann Rheum Dis. 2010; 69(8): 1420-2. PubMed

van den Hoogen F, Khanna D, Fransen J, Johnson SR, Baron M, Tyndall A, Matucci-Cerinic M, Naden RP, Medsger TA, Carreira PE, Riemekasten G, Clements PJ, Denton CP, Distler O, Allanore Y, Furst DE, Gabrielli A, Mayes MD, van Laar JM, Seibold JR, Czirjak L, Steen VD, Inanc M, Kowal-Bielecka O, Müller-Ladner U, Valentini G, Veale DJ, Vonk MC, Walker UA, Chung L, Collier DH, Csuka ME, Fessler BJ, Guiducci S, Herrick A, Hsu VM, Jimenez S, Kahaleh B, Merkel PA, Sierakowski S, Silver RM, Simms RW, Varga J, Pope JE. 2013 classification criteria for systemic sclerosis: an American College of Rheumatology/European League against Rheumatism collaborative initiative. Arthritis Rheum. 2013; 65(11): 2737-47. PubMed

General References

Fritzler MJ. The antinuclear antibody test: last or lasting gasp? Arthritis Rheum. 2011; 63(1): 19-22. PubMed

Ghirardello A, Bendo R, Rampudda ME, Bassi N, Zampieri S, Doria A. Commercial blot assays in the diagnosis of systemic rheumatic diseases. Autoimmun Rev. 2009; 8(8): 645-9. PubMed

Kumar S, Aggarwal A. Approach to a patient with connective tissue disease. Indian J Pediatr. 2010; 77(10): 1157-64. PubMed

Liu C, Ahearn JM. The search for lupus biomarkers. Best Pract Res Clin Rheumatol. 2009; 23(4): 507-23. PubMed

Mammen AL. Dermatomyositis and polymyositis: Clinical presentation, autoantibodies, and pathogenesis. Ann N Y Acad Sci. 2010; 1184: 134-53. PubMed

Schulte-Pelkum J, Fritzler M, Mahler M. Latest update on the Ro/SS-A autoantibody system. Autoimmun Rev. 2009; 8(7): 632-7. PubMed

Singh S, Mehra S. Approach to polyarthritis. Indian J Pediatr. 2010; 77(9): 1005-10. PubMed

Vaz CC, Couto M, Medeiros D, Miranda L, Costa J, Nero P, Barros R, Santos MJ, Sousa E, Barcelos A, Inês L. Undifferentiated connective tissue disease: a seven-center cross-sectional study of 184 patients. Clin Rheumatol. 2009; 28(8): 915-21. PubMed

Medical Reviewers

Tebo, Anne E., PhD, D(ABMLI), Medical Director, Immunology at ARUP Laboratories; Associate Professor of Clinical Pathology, University of Utah

Last Update: September 2016

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